Provider Demographics
NPI:1760985212
Name:VASSELL, MARCUS MALCOLM
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:MALCOLM
Last Name:VASSELL
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 1:20 SICKLES AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-4030
Mailing Address - Country:US
Mailing Address - Phone:646-675-9248
Mailing Address - Fax:
Practice Address - Street 1:20 SICKLES AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4030
Practice Address - Country:US
Practice Address - Phone:646-675-9248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)