Basic Information
| Provider Information | |||||||||
| NPI: | 1053628610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | MARLON | ||||||||
| MiddleName: | GERMAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3356 | ||||||||
| Address2: | |||||||||
| City: | EDGARTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025393356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088161698 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 EDGARTOWN VINEYARD HAVEN RD | ||||||||
| Address2: | |||||||||
| City: | VINEYARD HAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025684036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
| FaxNumber: | 5086960401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2010 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 146N00000X | 875586 | MA | N | Emergency Medical Service Providers | Emergency Medical Technician, Basic |
No ID Information.