Provider Demographics
NPI:1942343439
Name:ST CLAIR, MARVIN OTIS III (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:OTIS
Last Name:ST CLAIR
Suffix:III
Gender:M
Credentials:LCSW
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 575
Mailing Address - Street 2:
Mailing Address - City:VOLCANO
Mailing Address - State:HI
Mailing Address - Zip Code:96785-0575
Mailing Address - Country:US
Mailing Address - Phone:808-961-5166
Mailing Address - Fax:808-934-0071
Practice Address - Street 1:113850 6TH
Practice Address - Street 2:
Practice Address - City:VOLCANO
Practice Address - State:HI
Practice Address - Zip Code:96785
Practice Address - Country:US
Practice Address - Phone:808-967-8580
Practice Address - Fax:808-934-0071
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI536336Medicaid
HI0000252791OtherHMSA PROVIDER NUMBER