Provider Demographics
NPI:1427082312
Name:MARNOCHA, MARK R (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MARNOCHA
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:W8553 HICKORY CT
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944-9651
Mailing Address - Country:US
Mailing Address - Phone:920-779-0406
Mailing Address - Fax:
Practice Address - Street 1:229 S MORRISON ST
Practice Address - Street 2:FOX VALLEY FAMILY MEDICINE
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5725
Practice Address - Country:US
Practice Address - Phone:920-997-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1671103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1427082312Medicaid