Provider Demographics
NPI:1891933222
Name:MARRIAGE FULLY ALIVE LLC
Entity Type:Organization
Organization Name:MARRIAGE FULLY ALIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:
Authorized Official - Phone:214-629-6133
Mailing Address - Street 1:1506 N GREENVILLE AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-8692
Mailing Address - Country:US
Mailing Address - Phone:214-629-6133
Mailing Address - Fax:972-943-7128
Practice Address - Street 1:1506 N GREENVILLE AVE STE 250
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-8692
Practice Address - Country:US
Practice Address - Phone:214-629-6133
Practice Address - Fax:972-943-7128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2200944106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty