Provider Demographics
NPI:1245096999
Name:WEATHERALL, MARCENE R (LCDC)
Entity type:Individual
Prefix:
First Name:MARCENE
Middle Name:R
Last Name:WEATHERALL
Suffix:
Gender:
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5613 MOUNT STORM WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4438
Mailing Address - Country:US
Mailing Address - Phone:773-996-3797
Mailing Address - Fax:
Practice Address - Street 1:5613 MOUNT STORM WAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-4438
Practice Address - Country:US
Practice Address - Phone:773-996-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health