Provider Demographics
NPI:1154365955
Name:MARKS, ROY C (MA, LCSW)
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:C
Last Name:MARKS
Suffix:
Gender:M
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 GRANT PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3304
Mailing Address - Country:US
Mailing Address - Phone:314-721-2155
Mailing Address - Fax:314-457-0611
Practice Address - Street 1:5524 GRANT PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-3304
Practice Address - Country:US
Practice Address - Phone:314-721-2155
Practice Address - Fax:314-457-0611
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002304103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498301100Medicaid