Basic Information
| Provider Information | |||||||||
| NPI: | 1932476678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRICE | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 S RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618213232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155494663 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 311 WHITE ST | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173988080 | ||||||||
| FaxNumber: | 2173595276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2011 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.