Provider Demographics
NPI:1558360958
Name:ABBOTT, MARCIA M (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:M
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 58TH ST
Mailing Address - Street 2:#600
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-2000
Mailing Address - Country:US
Mailing Address - Phone:806-792-3808
Mailing Address - Fax:806-792-1506
Practice Address - Street 1:5502 58TH ST
Practice Address - Street 2:#600
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-2000
Practice Address - Country:US
Practice Address - Phone:806-792-3808
Practice Address - Fax:806-792-1506
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2422103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75193591779414OtherCHAMPUS/TRI-CARE
TX001471Medicare ID - Type UnspecifiedPROVIDER NUMBER