Provider Demographics
NPI:1003328063
Name:WHITLEY, MARSHON (LCDCIII)
Entity Type:Individual
Prefix:
First Name:MARSHON
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44303-1438
Mailing Address - Country:US
Mailing Address - Phone:330-379-3467
Mailing Address - Fax:330-379-3465
Practice Address - Street 1:665 W MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44303-1438
Practice Address - Country:US
Practice Address - Phone:330-379-3467
Practice Address - Fax:330-379-3465
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH981010101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847709Medicaid