Provider Demographics
NPI:1407534621
Name:MARSHALL, MAX BENJAMIN
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:BENJAMIN
Last Name:MARSHALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 W WILSON AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1096
Mailing Address - Country:US
Mailing Address - Phone:773-576-4689
Mailing Address - Fax:
Practice Address - Street 1:934 W WILSON AVE APT 1D
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1096
Practice Address - Country:US
Practice Address - Phone:773-576-4689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.112617104100000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor