Provider Demographics
NPI:1760808133
Name:MARRIAGE FULLY ALIVE COACHING AND COUNSELING
Entity Type:Organization
Organization Name:MARRIAGE FULLY ALIVE COACHING AND COUNSELING
Other - Org Name:SIMPLE MARRIAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:214-629-6133
Mailing Address - Street 1:4502 BELLCREST DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-7749
Mailing Address - Country:US
Mailing Address - Phone:214-629-6133
Mailing Address - Fax:
Practice Address - Street 1:6951 VIRGINIA PKWY
Practice Address - Street 2:SUITE 320
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070
Practice Address - Country:US
Practice Address - Phone:214-629-6133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18693101YP2500X
TX200944106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty