Provider Demographics
NPI:1639780828
Name:WASHINGTON, MARCELLIS DOMINIQUE (PLPC)
Entity Type:Individual
Prefix:
First Name:MARCELLIS
Middle Name:DOMINIQUE
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 NE 67TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64119-7872
Mailing Address - Country:US
Mailing Address - Phone:816-769-3845
Mailing Address - Fax:
Practice Address - Street 1:8010 N ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64119-8600
Practice Address - Country:US
Practice Address - Phone:816-769-3845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YS0200X
MO2021035831101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1427526466Medicaid