Provider Demographics
NPI:1700393527
Name:THEODORE, MARVIN
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
Last Name:THEODORE
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 1:263 PORT RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1704
Mailing Address - Country:US
Mailing Address - Phone:718-981-8117
Mailing Address - Fax:
Practice Address - Street 1:263 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1704
Practice Address - Country:US
Practice Address - Phone:718-981-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33621101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty