Provider Demographics
NPI:1992374151
Name:LOWE, MARI-BREANNA
Entity Type:Individual
Prefix:
First Name:MARI-BREANNA
Middle Name:
Last Name:LOWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 KELLER PKWY STE B302
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2479
Mailing Address - Country:US
Mailing Address - Phone:817-562-8731
Mailing Address - Fax:817-562-8222
Practice Address - Street 1:816 KELLER PKWY STE B302
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2479
Practice Address - Country:US
Practice Address - Phone:817-562-8731
Practice Address - Fax:817-562-8222
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4190103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4190OtherSTATE LICENSE
1-21-49354OtherBACB CERTIFICATION NUMBER