Provider Demographics
NPI:1730414053
Name:MARSHALL, EDMOND LAMAR SR
Entity type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:LAMAR
Last Name:MARSHALL
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 STRATHWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ROLESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27571-9012
Mailing Address - Country:US
Mailing Address - Phone:919-280-0179
Mailing Address - Fax:
Practice Address - Street 1:2310 S MIAMI BLVD
Practice Address - Street 2:STE 135
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-5798
Practice Address - Country:US
Practice Address - Phone:919-280-0179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-04
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC717C231041C0700X, 251S00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health