Basic Information
Provider Information | |||||||||
NPI: | 1629117734 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARSHALL | ||||||||
FirstName: | THERESA | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 445 E SHERMAN BLVD | ||||||||
Address2: |   | ||||||||
City: | MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494442203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317394359 | ||||||||
FaxNumber: | 2317336151 | ||||||||
Practice Location | |||||||||
Address1: | 2700 BAKER ST FL 3 | ||||||||
Address2: |   | ||||||||
City: | MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494442157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317371335 | ||||||||
FaxNumber: | 2317370534 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2007 | ||||||||
LastUpdateDate: | 01/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801087866 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 6801087866 | MI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 1629066238 | 05 | MI |   | MEDICAID | 231858 | 05 | MI |   | MEDICAID | 4483587 | 05 | MI |   | MEDICAID |