Provider Demographics
NPI:1053478800
Name:MARSHALL, RONALD CLEMENS (PHD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:CLEMENS
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 CHARLEVOIX AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8421
Mailing Address - Country:US
Mailing Address - Phone:231-348-0800
Mailing Address - Fax:231-348-0800
Practice Address - Street 1:2810 CHARLEVOIX AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8421
Practice Address - Country:US
Practice Address - Phone:231-348-0800
Practice Address - Fax:231-348-0800
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005055103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOB44544Medicare ID - Type UnspecifiedPSYCHOLOGIST