Provider Demographics
NPI:1386951978
Name:IRWIN, MARC HANNA (PHD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:HANNA
Last Name:IRWIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 ANDREA DR
Mailing Address - Street 2:SUITE 4, BUILDING E
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6726
Mailing Address - Country:US
Mailing Address - Phone:505-324-5855
Mailing Address - Fax:
Practice Address - Street 1:851 ANDREA DR
Practice Address - Street 2:SUITE 4, BUILDING E
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6726
Practice Address - Country:US
Practice Address - Phone:505-324-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM251103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
320059Medicare Oscar/Certification