Basic Information
| Provider Information | |||||||||
| NPI: | 1568437226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 HOSPITAL DR. | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508337400 | ||||||||
| FaxNumber: | 8508337528 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 HOSPITAL DR. | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508337400 | ||||||||
| FaxNumber: | 8508337528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH 5996 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 761863800 | 05 | FL | MEDICAID |