Provider Demographics
NPI:1275815532
Name:MARSHALL, MATTHEW R
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:R
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 1:821 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3125
Mailing Address - Country:US
Mailing Address - Phone:417-230-5132
Mailing Address - Fax:
Practice Address - Street 1:1015 HWY 248
Practice Address - Street 2:SUITE I
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-8001
Practice Address - Country:US
Practice Address - Phone:417-429-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011030017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional