Provider Demographics
NPI:1760827794
Name:VICKERMAN, MARION MAROLD (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:MAROLD
Last Name:VICKERMAN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CANYON LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-3701
Mailing Address - Country:US
Mailing Address - Phone:409-200-2220
Mailing Address - Fax:409-440-3344
Practice Address - Street 1:4749 ODOM RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7080
Practice Address - Country:US
Practice Address - Phone:409-200-2220
Practice Address - Fax:409-440-3344
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO 613106H00000X
TX202574106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist