Healthcare Provider Details

I. General information

NPI: 1790351138
Provider Name (Legal Business Name): MICHAEL L MARCUM LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N JEFFERSON AVE
SAINT LOUIS MO
63103-3000
US

IV. Provider business mailing address

515 N JEFFERSON AVE
SAINT LOUIS MO
63103-3000
US

V. Phone/Fax

Practice location:
  • Phone: 314-934-8448
  • Fax:
Mailing address:
  • Phone: 314-934-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.019042
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: