Basic Information
| Provider Information | |||||||||
| NPI: | 1215382247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CAC I, MAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9220 EDWARDS WAY APT 2232 | ||||||||
| Address2: | |||||||||
| City: | ADELPHI | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207833415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022367756 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1627 KENILWORTH AVE NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200192010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028032340 | ||||||||
| FaxNumber: | 2028032350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2016 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CAC I 1145 | DC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 082390200 | 05 | DC | MEDICAID |