Provider Demographics
NPI:1992835953
Name:DECOSTER, MARION BURKHALTER (MSW)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:BURKHALTER
Last Name:DECOSTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MARION
Other - Middle Name:LUND
Other - Last Name:BURKHALTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PSC 704 BOX 2783
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96338
Mailing Address - Country:US
Mailing Address - Phone:240-233-2739
Mailing Address - Fax:
Practice Address - Street 1:PSC 704 BOX 2783
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96338
Practice Address - Country:US
Practice Address - Phone:240-233-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD014971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQW50Medicare UPIN