Provider Demographics
NPI:1124264544
Name:MARSHALL, BERNARD MARY (PHD)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:MARY
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:861 CONVERSE ST
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1716
Mailing Address - Country:US
Mailing Address - Phone:413-565-4648
Mailing Address - Fax:413-847-0864
Practice Address - Street 1:140 HIGH STREET
Practice Address - Street 2:CHILD PARTIAL HOSPITAL PROGRAM W- 2 WMB
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01190
Practice Address - Country:US
Practice Address - Phone:413-794-8677
Practice Address - Fax:413-794-2181
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1059881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3793Medicare PIN