Provider Demographics
NPI:1548473903
Name:SUNDSTROM, MARK VINCENT (MS,LICSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:VINCENT
Last Name:SUNDSTROM
Suffix:
Gender:M
Credentials:MS,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1413
Mailing Address - Country:US
Mailing Address - Phone:304-574-2100
Mailing Address - Fax:304-574-2151
Practice Address - Street 1:209 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1413
Practice Address - Country:US
Practice Address - Phone:304-574-2100
Practice Address - Fax:304-574-2151
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP004504721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2020561Medicare PIN