Healthcare Provider Details

I. General information

NPI: 1225645765
Provider Name (Legal Business Name): PETER MARLOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD STE 1201
CHICAGO IL
60604-4192
US

IV. Provider business mailing address

2719 W SCHUBERT AVE APT 3
CHICAGO IL
60647-1833
US

V. Phone/Fax

Practice location:
  • Phone: 312-772-9796
  • Fax:
Mailing address:
  • Phone: 616-970-1954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: