Provider Demographics
NPI:1619255031
Name:GOSS, MARCUS DERRELL
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:DERRELL
Last Name:GOSS
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 1:12107 HERITAGE PARK RD
Mailing Address - Street 2:136
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9514
Mailing Address - Country:US
Mailing Address - Phone:707-731-3357
Mailing Address - Fax:
Practice Address - Street 1:12107 HERITAGE PARK RD
Practice Address - Street 2:136
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9514
Practice Address - Country:US
Practice Address - Phone:707-731-3357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst