Healthcare Provider Details

I. General information

NPI: 1730414053
Provider Name (Legal Business Name): MR. EDMOND LAMAR MARSHALL SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2009
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 S MIAMI BLVD STE 135
DURHAM NC
27703-5798
US

IV. Provider business mailing address

717 STRATHWOOD WAY
ROLESVILLE NC
27571-9012
US

V. Phone/Fax

Practice location:
  • Phone: 919-280-0179
  • Fax:
Mailing address:
  • Phone: 919-280-0179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number717C23
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number717C23
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number717C23
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: