Provider Demographics
NPI:1982958070
Name:HOWARD, MARCUS LAVON
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:LAVON
Last Name:HOWARD
Suffix:
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 1:4400 S 202ND EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-1593
Mailing Address - Country:US
Mailing Address - Phone:918-402-1290
Mailing Address - Fax:918-355-7006
Practice Address - Street 1:6202 S LEWIS AVE
Practice Address - Street 2:STE, H
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1099
Practice Address - Country:US
Practice Address - Phone:918-949-4086
Practice Address - Fax:918-949-3638
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid