Provider Demographics
NPI:1225651714
Name:MARCON, CAROLINE ROSE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ROSE
Last Name:MARCON
Suffix:
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 1:7794 PAINT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15227 PAYNE CT
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3030
Practice Address - Country:US
Practice Address - Phone:313-590-6029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-06-25
Deactivation Date:2020-05-31
Deactivation Code:
Reactivation Date:2020-06-25
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist