Healthcare Provider Details

I. General information

NPI: 1043666506
Provider Name (Legal Business Name): MARCUS VAN SICKLE PH.D., ABPP, MPAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 REMOUNT RD BLDG 3107
NORTH CHARLESTON SC
29406-3516
US

IV. Provider business mailing address

9861 BROKEN LAND PKWY STE 100
COLUMBIA MD
21046-3031
US

V. Phone/Fax

Practice location:
  • Phone: 571-607-2055
  • Fax:
Mailing address:
  • Phone: 202-209-3406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number340254
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: