Healthcare Provider Details

I. General information

NPI: 1639093057
Provider Name (Legal Business Name): GENESIS MARROQUIN LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7326 BROAD RIVER RD
IRMO SC
29063-9861
US

IV. Provider business mailing address

2277 SUNSET BLVD
WEST COLUMBIA SC
29169-4713
US

V. Phone/Fax

Practice location:
  • Phone: 888-796-1117
  • Fax: 803-996-5228
Mailing address:
  • Phone: 888-796-1117
  • Fax: 803-996-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11057
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: