Provider Demographics
NPI:1295352888
Name:WINDHOM, MARCUS E SR
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:E
Last Name:WINDHOM
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 MONROE HL APT 310
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-6552
Mailing Address - Country:US
Mailing Address - Phone:404-625-5907
Mailing Address - Fax:
Practice Address - Street 1:150 SESSIONS DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2317
Practice Address - Country:US
Practice Address - Phone:404-625-5907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X, 172V00000X, 252Y00000X, 171M00000X
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker
No252Y00000XAgenciesEarly Intervention Provider Agency