Provider Demographics
NPI:1750509352
Name:SPIVAK, MARK STEPHEN (LICSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
Last Name:SPIVAK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 FENNO DR
Mailing Address - Street 2:
Mailing Address - City:ROWLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01969-1005
Mailing Address - Country:US
Mailing Address - Phone:978-948-5505
Mailing Address - Fax:978-948-5505
Practice Address - Street 1:25 STATE ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-6614
Practice Address - Country:US
Practice Address - Phone:978-948-5505
Practice Address - Fax:978-948-5505
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1052491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9397164Medicare UPIN
MAP03407Medicare UPIN
MA778558Medicare UPIN
MA7845096Medicare UPIN
MA66084Medicare UPIN
MDO95154Medicare UPIN
MA5644-01Medicare UPIN
MA62-442-68Medicare UPIN
MAO12837Medicare UPIN
MAP03407Medicare ID - Type UnspecifiedPROVIDER NUMBER