Provider Demographics
NPI:1124770771
Name:MARCUS, MARCELLA
Entity type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:MARCUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 N 56TH AVE APT 801
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2261
Mailing Address - Country:US
Mailing Address - Phone:954-557-3739
Mailing Address - Fax:
Practice Address - Street 1:3680 N 56TH AVE APT 801
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2261
Practice Address - Country:US
Practice Address - Phone:954-557-3739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB538632106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician