Provider Demographics
NPI:1285760702
Name:MARCUS, PHYLLIS C (MS)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:C
Last Name:MARCUS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:JANE
Other - Last Name:CRAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:635 SW 14TH TER APT 8
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-7280
Mailing Address - Country:US
Mailing Address - Phone:954-304-2399
Mailing Address - Fax:954-497-3857
Practice Address - Street 1:540 NW 165TH ST STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-6304
Practice Address - Country:US
Practice Address - Phone:786-648-6550
Practice Address - Fax:786-648-6505
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9698101YM0800X
FLMT2404106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767784700Medicaid