Provider Demographics
NPI:1518905157
Name:MONGHATE, MARCIA MARLENE
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:MARLENE
Last Name:MONGHATE
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 1:1119 W RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-3016
Mailing Address - Country:US
Mailing Address - Phone:972-572-2949
Mailing Address - Fax:
Practice Address - Street 1:8059 SCYENE CIR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-5562
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX418304364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9606OtherBLUE CROSS BLUE SHIELD
TX8N9606OtherBLUE CROSS BLUE SHIELD