1932329497 NPI number — MS. MARSHA DIANE MCCLEAN AUDIOLOGIST

Table of content: MS. MARSHA DIANE MCCLEAN AUDIOLOGIST (NPI 1932329497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932329497 NPI number — MS. MARSHA DIANE MCCLEAN AUDIOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLEAN
Provider First Name:
MARSHA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AUDIOLOGIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932329497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1821 MARTEL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76103-1411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-293-9009
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12001 SOUTH FWY #201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-293-9009
Provider Business Practice Location Address Fax Number:
817-293-9013
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  50429 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00406U . This is a "GROUP #CONNECTED WITH PRECEEDING PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 50429 . This is a "STATE AUDIOLOGY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8L10430 . This is a "INDIVIDUAL MEDICARE PTAN WITHIN GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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