Provider Demographics
NPI:1104281518
Name:MARJASON, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MARJASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 RUTLAND DR
Mailing Address - Street 2:
Mailing Address - City:HALLSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75650-6213
Mailing Address - Country:US
Mailing Address - Phone:903-736-6818
Mailing Address - Fax:
Practice Address - Street 1:1300 N 6TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5567
Practice Address - Country:US
Practice Address - Phone:903-297-1852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX564361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX56436OtherTEXAS STATE BOARD OF SOCIAL WORKER EXAMINERS