Healthcare Provider Details

I. General information

NPI: 1407534621
Provider Name (Legal Business Name): MR. MAX BENJAMIN MARSHALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 W WILSON AVE APT 1D
CHICAGO IL
60640-1096
US

IV. Provider business mailing address

934 W WILSON AVE APT 1D
CHICAGO IL
60640-1096
US

V. Phone/Fax

Practice location:
  • Phone: 773-576-4689
  • Fax:
Mailing address:
  • Phone: 773-576-4689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.112617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: