Provider Demographics
NPI:1477739613
Name:CHURCH, MARCIA A (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:A
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6462
Mailing Address - Country:US
Mailing Address - Phone:682-800-2228
Mailing Address - Fax:682-323-2028
Practice Address - Street 1:1560 E SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6462
Practice Address - Country:US
Practice Address - Phone:682-800-2228
Practice Address - Fax:682-323-2028
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105673Medicaid