Provider Demographics
NPI:1467194183
Name:MARSHALL, PATRICE ANN
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:ANN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 MEDICAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828
Mailing Address - Country:US
Mailing Address - Phone:541-805-5954
Mailing Address - Fax:
Practice Address - Street 1:606 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828
Practice Address - Country:US
Practice Address - Phone:541-805-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging