Provider Demographics
NPI:1477709434
Name:MARLEY, VINCE
Entity Type:Individual
Prefix:MR
First Name:VINCE
Middle Name:
Last Name:MARLEY
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:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-0163
Mailing Address - Country:US
Mailing Address - Phone:336-495-5647
Mailing Address - Fax:336-495-5647
Practice Address - Street 1:219 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-7249
Practice Address - Country:US
Practice Address - Phone:336-226-9716
Practice Address - Fax:336-226-9716
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-001-161322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children