Provider Demographics
NPI:1437140092
Name:ISAJIW, MARK WSEVOLOD (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WSEVOLOD
Last Name:ISAJIW
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 53, BOX 1861
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09601
Mailing Address - Country:IT
Mailing Address - Phone:043-430-5321
Mailing Address - Fax:0-434-5668
Practice Address - Street 1:UNIT 6180, BOX 245
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604-0245
Practice Address - Country:IT
Practice Address - Phone:043-430-5321
Practice Address - Fax:043-430-5668
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004144101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health