Healthcare Provider Details

I. General information

NPI: 1235654567
Provider Name (Legal Business Name): JUSTIN MARSHALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 N VAN NESS AVE
FRESNO CA
93728-3419
US

IV. Provider business mailing address

1021 FREMONT AVE
SOUTH LAKE TAHOE CA
96150-8136
US

V. Phone/Fax

Practice location:
  • Phone: 559-266-9581
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC041190317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: