Provider Demographics
NPI:1710347752
Name:MARSHALL, SEAN TRAVIS (CSW)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:TRAVIS
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 GIBSON LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2577
Mailing Address - Country:US
Mailing Address - Phone:859-623-9367
Mailing Address - Fax:859-623-9389
Practice Address - Street 1:415 GIBSON LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2577
Practice Address - Country:US
Practice Address - Phone:859-623-9367
Practice Address - Fax:859-623-9389
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7150104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid