Provider Demographics
NPI:1851868319
Name:STURDIVANT, MARILYN (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 541314
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-1314
Mailing Address - Country:US
Mailing Address - Phone:214-240-8636
Mailing Address - Fax:
Practice Address - Street 1:1201 N WATSON RD STE 100-F
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-6190
Practice Address - Country:US
Practice Address - Phone:817-989-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX604391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX60439OtherTEXAS STATE BOARD OF SOCIAL WORKER EXAMINERS