Provider Demographics
NPI:1790390615
Name:MARSHALL, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARSHALL
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:PO BOX 1231
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929-1231
Mailing Address - Country:US
Mailing Address - Phone:907-874-5008
Mailing Address - Fax:
Practice Address - Street 1:110 LYNCH STREET
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929-1231
Practice Address - Country:US
Practice Address - Phone:907-874-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA225700000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist