Provider Demographics
NPI:1770947137
Name:MARSH, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MARSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E SWANNANOA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-3002
Mailing Address - Country:US
Mailing Address - Phone:336-633-0252
Mailing Address - Fax:336-622-0252
Practice Address - Street 1:615 E SWANNANOA AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-3002
Practice Address - Country:US
Practice Address - Phone:336-622-0252
Practice Address - Fax:336-622-0252
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-076-125320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities