Provider Demographics
NPI:1093194664
Name:MARSHALL, NASTASSJA (PHD)
Entity Type:Individual
Prefix:
First Name:NASTASSJA
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 PARKWOOD AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-3519
Mailing Address - Country:US
Mailing Address - Phone:917-753-7593
Mailing Address - Fax:
Practice Address - Street 1:3111 NORTHSIDE AVE STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5441
Practice Address - Country:US
Practice Address - Phone:917-753-7593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0810005475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program