Provider Demographics
NPI:1487124517
Name:PRINCE, MARK ANTHONY (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:PRINCE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 SNOWBRUSH PL
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-7549
Mailing Address - Country:US
Mailing Address - Phone:619-994-1518
Mailing Address - Fax:
Practice Address - Street 1:1876 CAMPUS DELIVERY # CLARKC07
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-1876
Practice Address - Country:US
Practice Address - Phone:619-994-1518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-02
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004925103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical