Provider Demographics
NPI:1760948483
Name:CHAVEZ, MARCUS GERARD
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:GERARD
Last Name:CHAVEZ
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 1:5991 CERULEAN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-2652
Mailing Address - Country:US
Mailing Address - Phone:657-340-9405
Mailing Address - Fax:
Practice Address - Street 1:713 WEST COMMONWEALTH SUITE A
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:U.S.A
Practice Address - Zip Code:92832
Practice Address - Country:UM
Practice Address - Phone:714-879-4274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst