Basic Information
| Provider Information | |||||||||
| NPI: | 1205088358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | ANGEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 CHARLIE DIXON RD | ||||||||
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| City: | BRAXTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390449314 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 206 MARYLAND AVE | ||||||||
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| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396483926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012504815 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1195 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.