Provider Demographics
NPI:1922654201
Name:MARVAL, TITAN COLBY (CRM, PSSAD)
Entity Type:Individual
Prefix:
First Name:TITAN
Middle Name:COLBY
Last Name:MARVAL
Suffix:
Gender:M
Credentials:CRM, PSSAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N.E. MENZANITA AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1400
Mailing Address - Country:US
Mailing Address - Phone:541-479-8847
Mailing Address - Fax:541-471-2679
Practice Address - Street 1:109 N.E. MENZANITA AVENUE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1400
Practice Address - Country:US
Practice Address - Phone:541-479-8847
Practice Address - Fax:541-471-2679
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-CRM-084175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR19-CRM-084OtherMHACBO