Provider Demographics
NPI:1174909683
Name:ALLEN, MARCUS WILLIAM (MA)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:WILLIAM
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4076 MIZNER CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4300
Mailing Address - Country:US
Mailing Address - Phone:904-614-8070
Mailing Address - Fax:
Practice Address - Street 1:4076 MIZNER CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4300
Practice Address - Country:US
Practice Address - Phone:904-614-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1712101YM0800X
FL1179106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health