Provider Demographics
NPI:1407577901
Name:SHAKUR-PURVIS, MARKIM
Entity Type:Individual
Prefix:
First Name:MARKIM
Middle Name:
Last Name:SHAKUR-PURVIS
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 1:201A BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-7806
Mailing Address - Country:US
Mailing Address - Phone:732-682-4343
Mailing Address - Fax:
Practice Address - Street 1:183 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2757
Practice Address - Country:US
Practice Address - Phone:973-972-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00160000101YA0400X
NJ37PC00471600101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)