Provider Demographics
NPI:1144779562
Name:DIAMOND, MARCIE (PTA)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 ACTON HWY STE 106
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-3105
Mailing Address - Country:US
Mailing Address - Phone:817-326-1375
Mailing Address - Fax:817-326-2068
Practice Address - Street 1:5310 ACTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-3105
Practice Address - Country:US
Practice Address - Phone:817-326-1375
Practice Address - Fax:817-326-2068
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2121839225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant