Provider Demographics
NPI:1356824734
Name:MARCUS, MIKE
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:MARCUS
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 1:927 CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4110
Mailing Address - Country:US
Mailing Address - Phone:307-272-8085
Mailing Address - Fax:
Practice Address - Street 1:927 CANYON AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4110
Practice Address - Country:US
Practice Address - Phone:307-272-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool