Provider Demographics
NPI:1073837456
Name:MARSHALL, THERENCE TAMIKO SR
Entity Type:Individual
Prefix:MISS
First Name:THERENCE
Middle Name:TAMIKO
Last Name:MARSHALL
Suffix:SR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 COLLEGE DR
Mailing Address - Street 2:UNIT#97
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-1861
Mailing Address - Country:US
Mailing Address - Phone:225-636-7178
Mailing Address - Fax:225-647-2200
Practice Address - Street 1:2100 COLLEGE DR
Practice Address - Street 2:UNIT#97
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-1861
Practice Address - Country:US
Practice Address - Phone:225-636-7178
Practice Address - Fax:225-647-2200
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07220572172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker