Provider Demographics
NPI:1649845116
Name:BLAND, MARCUS THEA (MED,RBT)
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:THEA
Last Name:BLAND
Suffix:
Gender:M
Credentials:MED,RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17610 FOX BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:VA
Mailing Address - Zip Code:23830-2307
Mailing Address - Country:US
Mailing Address - Phone:804-490-8760
Mailing Address - Fax:
Practice Address - Street 1:2820 WATERFORD LAKE DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3994
Practice Address - Country:US
Practice Address - Phone:804-658-4509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-18-52170106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician