Healthcare Provider Details

I. General information

NPI: 1801724703
Provider Name (Legal Business Name): MARCUS GAVIN BEAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

IV. Provider business mailing address

2901 BLEDSOE ST APT 2303
FT WORTH TX
76107-2827
US

V. Phone/Fax

Practice location:
  • Phone: 866-610-0580
  • Fax:
Mailing address:
  • Phone: 505-249-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1415571
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: