MEDICARE: MARCUS CHARLES

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1578214565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS CHARLES

Provider Business Mailing Address
First Line	:	1211 RIDGEMONT ST
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-6682
Country	:	US
Telephone Number	:	281-636-1930
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 DEEP WOOD DR STE 99
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-4935
Country	:	US
Telephone Number	:	512-815-3723
Fax Number	:

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

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	01/12/2022

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Directions to “ MARCUS CHARLES ” Practice Location

Language	Start Address	Practice Location

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