Provider Demographics
NPI:1407916224
Name:SMALL, MARCUS H (MS)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:H
Last Name:SMALL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 REGENTS CIR
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2972
Mailing Address - Country:US
Mailing Address - Phone:415-491-0708
Mailing Address - Fax:415-472-7140
Practice Address - Street 1:639 DRAKE AVE.
Practice Address - Street 2:
Practice Address - City:MARIN CITY
Practice Address - State:CA
Practice Address - Zip Code:94965
Practice Address - Country:US
Practice Address - Phone:707-322-4971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25851106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist