Basic Information
Provider Information
NPI: 1003007790
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PRUDEN
FirstName: MARK
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: L.P.C.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 19971
Address2:  
City: CINCINNATI
State: OH
PostalCode: 452190971
CountryCode: US
TelephoneNumber: 5138616543
FaxNumber: 5133810016
Practice Location
Address1: 42 CALHOUN ST
Address2:  
City: CINCINNATI
State: OH
PostalCode: 452191525
CountryCode: US
TelephoneNumber: 5138616543
FaxNumber: 5133810016
Other Information
ProviderEnumerationDate: 08/07/2007
LastUpdateDate: 01/15/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/15/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500XE1734OHY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


Home