Basic Information
| Provider Information | |||||||||
| NPI: | 1023116324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE ODESSA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488491223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2698385839 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 FULLER AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163363909 | ||||||||
| FaxNumber: | 6163362475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802076772 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 101YP2500X | 6401012192 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1715928 | 05 | MI | MEDICAID |