Provider Demographics
NPI:1740973619
Name:BACOTE, MARLON JERMAINE (RPRS, CSAC-S, QMHP-A)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:JERMAINE
Last Name:BACOTE
Suffix:
Gender:M
Credentials:RPRS, CSAC-S, QMHP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-3842
Mailing Address - Country:US
Mailing Address - Phone:804-988-2763
Mailing Address - Fax:
Practice Address - Street 1:309 W 20TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-3842
Practice Address - Country:US
Practice Address - Phone:804-988-2763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0735000006101YA0400X
VA0709023340101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)