Provider Demographics
NPI:1447317227
Name:MARCIL, RICHARD RENE JR (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RENE
Last Name:MARCIL
Suffix:JR
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 1:172 W WARREN AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4133
Mailing Address - Country:US
Mailing Address - Phone:407-894-8507
Mailing Address - Fax:407-894-2024
Practice Address - Street 1:172 W WARREN AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4133
Practice Address - Country:US
Practice Address - Phone:407-894-8507
Practice Address - Fax:407-894-2024
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5474103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54083Medicare PIN