Provider Demographics
NPI:1144553405
Name:BATES, MARCUS (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:
Last Name:BATES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0488
Mailing Address - Country:US
Mailing Address - Phone:434-572-2936
Mailing Address - Fax:434-572-4881
Practice Address - Street 1:424 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-5200
Practice Address - Country:US
Practice Address - Phone:434-572-2936
Practice Address - Fax:434-572-4881
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040072161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1700890761Medicaid