Provider Demographics
NPI:1205551710
Name:CARRADINE, MARTRICE TASHAE
Entity type:Individual
Prefix:
First Name:MARTRICE
Middle Name:TASHAE
Last Name:CARRADINE
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 1:6051 BRIDGE ST APT 6045B
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2620
Mailing Address - Country:US
Mailing Address - Phone:682-291-9910
Mailing Address - Fax:
Practice Address - Street 1:1652 KELLER PKWY STE 200
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3877
Practice Address - Country:US
Practice Address - Phone:682-291-9910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-237816106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician