Healthcare Provider Details

I. General information

NPI: 1396470902
Provider Name (Legal Business Name): MARKLE HURTT MARCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MCKINLEY BLVD APT 1E
TERRE HAUTE IN
47803-1665
US

IV. Provider business mailing address

6 MCKINLEY BLVD APT 1E
TERRE HAUTE IN
47803-1665
US

V. Phone/Fax

Practice location:
  • Phone: 812-262-4400
  • Fax:
Mailing address:
  • Phone: 812-262-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number872594569
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: