Provider Demographics
NPI:1689456394
Name:MARCUS, ALLY D
Entity Type:Individual
Prefix:
First Name:ALLY
Middle Name:D
Last Name:MARCUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NORTHAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:540-905-5090
Mailing Address - Fax:
Practice Address - Street 1:10706 CEDAR POST LANE
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22553-2255
Practice Address - Country:US
Practice Address - Phone:540-905-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0607879103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral