MEDICARE: MR. ROY C MARKS M.A., L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	002304	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154365955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROY C MARKS M.A., L.C.S.W.

Provider Business Mailing Address
First Line	:	5524 GRANT PL
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-3304
Country	:	US
Telephone Number	:	314-721-2155
Fax Number	:	314-457-0611

Provider Business Practice Location Address
First Line	:	5524 GRANT PL
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-3304
Country	:	US
Telephone Number	:	314-721-2155
Fax Number	:	314-457-0611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	07/19/2021

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