Basic Information
| Provider Information | |||||||||
| NPI: | 1700829900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPARTMENT 272801 | ||||||||
| Address2: | PO BOX 67000 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482672728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178416913 | ||||||||
| FaxNumber: | 5178416917 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177895971 | ||||||||
| FaxNumber: | 5177895718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401006358 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6401006358 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | 6802059251 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | 6401006358 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 6401006358 | 01 | MI | LICENSED COUNSELOR | OTHER |