Provider Demographics
NPI:1295935286
Name:OLEXA, MARK S (MA, LPC, LMSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:OLEXA
Suffix:
Gender:M
Credentials:MA, LPC, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 BROCKWOOD DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1336
Mailing Address - Country:US
Mailing Address - Phone:616-560-4036
Mailing Address - Fax:
Practice Address - Street 1:4829 E BELTLINE AVE NE
Practice Address - Street 2:BUILDING ONE, SUITE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9747
Practice Address - Country:US
Practice Address - Phone:616-560-4036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801046560104100000X
MI6401000047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional