Healthcare Provider Details

I. General information

NPI: 1457978322
Provider Name (Legal Business Name): PATRICK MARCOUX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 05/12/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 S MAIN ST STE 2
CLARKSTON MI
48346-1590
US

IV. Provider business mailing address

39 S MAIN ST STE 2
CLARKSTON MI
48346-1590
US

V. Phone/Fax

Practice location:
  • Phone: 269-830-3791
  • Fax: 844-538-1691
Mailing address:
  • Phone: 215-543-4221
  • Fax: 844-538-1691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK C MARCOUX
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 215-543-4221