Provider Demographics
NPI:1629117734
Name:MARSHALL, THERESA ELLEN (LMSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ELLEN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2203
Mailing Address - Country:US
Mailing Address - Phone:231-739-4359
Mailing Address - Fax:231-733-6151
Practice Address - Street 1:2700 BAKER ST FL 3
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-737-1335
Practice Address - Fax:231-737-0534
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087866104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629066238Medicaid
MI231858Medicaid
MI4483587Medicaid