Provider Demographics
NPI:1194399352
Name:MARSHALL, CHARLES T
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 STRAWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2833
Mailing Address - Country:US
Mailing Address - Phone:309-825-5070
Mailing Address - Fax:
Practice Address - Street 1:308 W CIRCLE DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-3700
Practice Address - Country:US
Practice Address - Phone:309-825-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer