Provider Demographics
NPI:1124648027
Name:SAMPLE, MARLA (MED, LPC, RPT)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MED, LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SARAH ST
Mailing Address - Street 2:
Mailing Address - City:EDNA
Mailing Address - State:TX
Mailing Address - Zip Code:77957-3451
Mailing Address - Country:US
Mailing Address - Phone:361-782-1576
Mailing Address - Fax:
Practice Address - Street 1:606 N WELLS ST
Practice Address - Street 2:
Practice Address - City:EDNA
Practice Address - State:TX
Practice Address - Zip Code:77957-2719
Practice Address - Country:US
Practice Address - Phone:361-782-1576
Practice Address - Fax:361-298-2363
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional