Provider Demographics
NPI:1770205569
Name:SUTTON, MARVIN (PRS)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:SUTTON
Suffix:
Gender:M
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 WATERVLIET AVE APT E
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2700
Mailing Address - Country:US
Mailing Address - Phone:513-437-7888
Mailing Address - Fax:
Practice Address - Street 1:7345 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4472
Practice Address - Country:US
Practice Address - Phone:513-437-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.003556175T00000X
OHCDCA.183096171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist