Provider Demographics
NPI:1891868600
Name:MARSHALL, GERALD BRUCE
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:BRUCE
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 1:28119 GRAND DUKE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5218
Mailing Address - Country:US
Mailing Address - Phone:248-476-2229
Mailing Address - Fax:248-476-4434
Practice Address - Street 1:28119 GRAND DUKE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5218
Practice Address - Country:US
Practice Address - Phone:248-476-2229
Practice Address - Fax:248-476-4434
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010664611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical