Healthcare Provider Details

I. General information

NPI: 1801477690
Provider Name (Legal Business Name): COREY MARSHALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 KENTUCKY ST
SCOTTDALE GA
30079-1124
US

IV. Provider business mailing address

610 KENTUCKY ST
SCOTTDALE GA
30079-1124
US

V. Phone/Fax

Practice location:
  • Phone: 770-696-6555
  • Fax:
Mailing address:
  • Phone: 770-696-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009862
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCSW009862
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: