Provider Demographics
NPI:1538178181
Name:MARSTON, EDWARD HARRISON (PHD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:HARRISON
Last Name:MARSTON
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 1:3235 VOLLMER RD
Mailing Address - Street 2:SUITE 119
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2013
Mailing Address - Country:US
Mailing Address - Phone:708-444-1012
Mailing Address - Fax:708-614-9449
Practice Address - Street 1:3235 VOLLMER RD
Practice Address - Street 2:SUITE 119
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2013
Practice Address - Country:US
Practice Address - Phone:708-444-1012
Practice Address - Fax:708-614-9449
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK24879Medicare ID - Type UnspecifiedMEMBER #