Provider Demographics
NPI:1407294937
Name:MARX, DAVID T (PSYD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:MARX
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 TROY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1521
Mailing Address - Country:US
Mailing Address - Phone:608-301-1235
Mailing Address - Fax:608-301-1236
Practice Address - Street 1:4536 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5917
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-653-2218
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3010-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3010-57OtherSTATE LICENSE