Basic Information
| Provider Information | |||||||||
| NPI: | 1396343711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARQUEZ | ||||||||
| FirstName: | MARCUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127 MALL BLVD | ||||||||
| Address2: | STE A #244 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923927666 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 E MOUNTAIN VIEW ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602567279 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2020 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.