Provider Demographics
NPI:1124141007
Name:MARCUS, GARY M (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:MARCUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:M
Other - Last Name:MARCUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1851 CENTRAL PL S STE 204
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7507
Mailing Address - Country:US
Mailing Address - Phone:425-235-7219
Mailing Address - Fax:253-856-0187
Practice Address - Street 1:1851 CENTRAL PL S STE 204
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7507
Practice Address - Country:US
Practice Address - Phone:425-235-7219
Practice Address - Fax:253-856-0187
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA1246103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist