Provider Demographics
NPI:1255716676
Name:HART, MARCUS CONTRELL (DD)
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:CONTRELL
Last Name:HART
Suffix:
Gender:M
Credentials:DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10240 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2029
Mailing Address - Country:US
Mailing Address - Phone:844-280-3276
Mailing Address - Fax:
Practice Address - Street 1:10240 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2029
Practice Address - Country:US
Practice Address - Phone:844-280-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP1600X, 101YP2500X
WIR0059417FA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No174H00000XOther Service ProvidersHealth Educator