Healthcare Provider Details

I. General information

NPI: 1467934216
Provider Name (Legal Business Name): COURTNEY H MARVIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 E BROADWAY AVE
JACKSON WY
83001-8642
US

IV. Provider business mailing address

PO BOX 1868
JACKSON WY
83001-1868
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-2046
  • Fax: 307-733-6289
Mailing address:
  • Phone: 307-733-2046
  • Fax: 307-733-6289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-379
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: