Basic Information
| Provider Information | |||||||||
| NPI: | 1396861928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | AVELYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3493 WOODS EDGE DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488646030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178863707 | ||||||||
| FaxNumber: | 5173491973 | ||||||||
| Practice Location | |||||||||
| Address1: | 3493 WOODS EDGE DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488646030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178863707 | ||||||||
| FaxNumber: | 5173491973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 06/29/2012 | ||||||||
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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 | 1041C0700X | 6801016708 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 138194 | 01 | MI | BLUE CARE NETWORK | OTHER | 1001650 | 01 | MI | MCLAREN | OTHER | 138194 | 01 | MI | VALUE OPTIONS | OTHER | 214678195 | 01 | MI | PHP-UBH | OTHER | 8008973350 | 01 | MI | MESSA - BLUE CROSS | OTHER |