Provider Demographics
NPI:1548349541
Name:AUGUSTINE, MARK WILLIAM (LMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:AUGUSTINE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-2169
Mailing Address - Country:US
Mailing Address - Phone:203-756-7287
Mailing Address - Fax:203-596-2789
Practice Address - Street 1:70 PINE ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-2169
Practice Address - Country:US
Practice Address - Phone:203-756-7287
Practice Address - Fax:203-596-2789
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000994106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004242327Medicaid