MEDICARE: MARLON JERMAINE BACOTE RPRS, CSAC-S, QMHP-A

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	0735000006	VA
2	101YM0800X	Mental Health Counselor	0709023340	VA

General Provider Information

NPI Number	:	1740973619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLON JERMAINE BACOTE RPRS, CSAC-S, QMHP-A

Provider Business Mailing Address
First Line	:	309 W 20TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-3842
Country	:	US
Telephone Number	:	804-988-2763
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 W 20TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-3842
Country	:	US
Telephone Number	:	804-988-2763
Fax Number	:

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

Provider Enumeration Date	:	05/29/2023
Last Update Date	:	05/29/2023

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