Provider Demographics
NPI:1518447531
Name:MARQUEZ, TRACIE ANN
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:ANN
Last Name:MARQUEZ
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 1:5632 OLD ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-5009
Mailing Address - Country:US
Mailing Address - Phone:817-939-5485
Mailing Address - Fax:
Practice Address - Street 1:5632 OLD ORCHARD DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-5009
Practice Address - Country:US
Practice Address - Phone:817-939-5485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105079225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist