MEDICARE: NASTASSJA MARSHALL PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	0810005475	VA

General Provider Information

NPI Number	:	1093194664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NASTASSJA MARSHALL PHD

Provider Business Mailing Address
First Line	:	3003 PARKWOOD AVE APT 106
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23221-3519
Country	:	US
Telephone Number	:	917-753-7593
Fax Number	:

Provider Business Practice Location Address
First Line	:	3111 NORTHSIDE AVE STE 101
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-5441
Country	:	US
Telephone Number	:	917-753-7593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	09/11/2018

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