Provider Demographics
NPI:1396861928
Name:MARSHALL, AVELYN (LMSW)
Entity Type:Individual
Prefix:
First Name:AVELYN
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3493 WOODS EDGE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-6030
Mailing Address - Country:US
Mailing Address - Phone:517-886-3707
Mailing Address - Fax:517-349-1973
Practice Address - Street 1:3493 WOODS EDGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6030
Practice Address - Country:US
Practice Address - Phone:517-886-3707
Practice Address - Fax:517-349-1973
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010167081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI138194OtherBLUE CARE NETWORK
MI1001650OtherMCLAREN
MI138194OtherVALUE OPTIONS
MI214678195OtherPHP-UBH
MI8008973350OtherMESSA - BLUE CROSS
MIP04080001Medicare ID - Type UnspecifiedMENTAL HEALTH