Provider Demographics
NPI:1548996408
Name:MARK, EMILY ROSE (LAC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:MARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1816 REMINGTON WAY APT 210
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-5470
Mailing Address - Country:US
Mailing Address - Phone:406-905-0632
Mailing Address - Fax:
Practice Address - Street 1:141 DISCOVERY DR STE 109
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4134
Practice Address - Country:US
Practice Address - Phone:406-905-0632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-56959101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTBBH-LAC-LIC-56959OtherMONTANA BOARD OF BEHAVIORAL HEALTH