=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831600618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARVELLOUS BEHAVIORAL HEALTH AND MEDIATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2017
-----------------------------------------------------
Last Update Date | 09/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 GRACE AVE STE B
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401-2494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-215-1808
-----------------------------------------------------
Fax | 850-215-1895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 GRACE AVE STE B
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401-2494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-215-1808
-----------------------------------------------------
Fax | 850-215-1895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MARVEL L. ESTES
-----------------------------------------------------
Credential | LMHC, CAP, NCC
-----------------------------------------------------
Telephone | 850-624-7898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MH12363
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------