Provider Demographics
NPI:1386397685
Name:WILFONG, MARSHALL THOMAS
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:THOMAS
Last Name:WILFONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-2219
Mailing Address - Country:US
Mailing Address - Phone:919-972-1252
Mailing Address - Fax:
Practice Address - Street 1:601 S CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-2219
Practice Address - Country:US
Practice Address - Phone:919-972-1252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty