Provider Demographics
NPI:1376188086
Name:MARSHALL DEVOLOPMENTAL THERAPY SERVICES INC
Entity Type:Organization
Organization Name:MARSHALL DEVOLOPMENTAL THERAPY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPLE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELICA
Authorized Official - Middle Name:N
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:317-388-8131
Mailing Address - Street 1:8650 COMMERCE PARK PL STE A1
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3174
Mailing Address - Country:US
Mailing Address - Phone:317-388-8131
Mailing Address - Fax:317-536-3585
Practice Address - Street 1:308 ESTES MILL RD
Practice Address - Street 2:
Practice Address - City:WALNUT GROVE
Practice Address - State:MS
Practice Address - Zip Code:39189-5043
Practice Address - Country:US
Practice Address - Phone:317-388-8131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty