Provider Demographics
NPI:1629451968
Name:KING, MARCELL (CDCA)
Entity Type:Individual
Prefix:
First Name:MARCELL
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1054
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:419-222-7044
Practice Address - Street 1:809 W VINE ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1054
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:419-222-7044
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1629451968251B00000X, 101Y00000X, 101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1629451968Medicaid
OH1629451968Medicare Oscar/Certification
OH1629451968Medicare NSC
OH1629451968Medicare PIN
OH1629451968Medicaid