Provider Demographics
NPI:1932329497
Name:MCCLEAN, MARSHA DIANE (AUDIOLOGIST)
Entity Type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:DIANE
Last Name:MCCLEAN
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1821 MARTEL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-1411
Mailing Address - Country:US
Mailing Address - Phone:817-293-9009
Mailing Address - Fax:
Practice Address - Street 1:12001 SOUTH FWY #201
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028
Practice Address - Country:US
Practice Address - Phone:817-293-9009
Practice Address - Fax:817-293-9013
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50429231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00406UOtherGROUP #CONNECTED WITH PRECEEDING PTAN
TX50429OtherSTATE AUDIOLOGY LICENSE
TX8L10430OtherINDIVIDUAL MEDICARE PTAN WITHIN GROUP