Provider Demographics
NPI:1053330282
Name:MARVALD, MARK (MSSA, LISW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MARVALD
Suffix:
Gender:M
Credentials:MSSA, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26777 LORAIN ROAD
Mailing Address - Street 2:STE 314
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3225
Mailing Address - Country:US
Mailing Address - Phone:440-476-3622
Mailing Address - Fax:
Practice Address - Street 1:26777 LORAIN ROAD
Practice Address - Street 2:STE 314
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3225
Practice Address - Country:US
Practice Address - Phone:440-476-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00002531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW13641Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER