Provider Demographics
NPI:1366013005
Name:HARGROVE, MARKUS ANTONIO
Entity Type:Individual
Prefix:
First Name:MARKUS
Middle Name:ANTONIO
Last Name:HARGROVE
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 1:4 HENCHMAN ST # B
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2453
Mailing Address - Country:US
Mailing Address - Phone:774-329-1863
Mailing Address - Fax:
Practice Address - Street 1:4 HENCHMAN ST # B
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2453
Practice Address - Country:US
Practice Address - Phone:774-329-1863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100018556454Medicaid