Provider Demographics
NPI:1174537476
Name:NOLL, MARK EDWIN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:NOLL
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Gender:M
Credentials:PHD
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Mailing Address - Street 1:158 NAPOLEON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5529
Mailing Address - Country:US
Mailing Address - Phone:219-465-7674
Mailing Address - Fax:219-462-0329
Practice Address - Street 1:158 NAPOLEON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5529
Practice Address - Country:US
Practice Address - Phone:219-465-7674
Practice Address - Fax:219-462-0329
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN20010455A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical