Provider Demographics
NPI:1356772289
Name:CLAY, MARQUITA Y
Entity type:Individual
Prefix:
First Name:MARQUITA
Middle Name:Y
Last Name:CLAY
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 1:17330 PRESTON RD
Mailing Address - Street 2:STE. 200D
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5997
Mailing Address - Country:US
Mailing Address - Phone:469-285-2530
Mailing Address - Fax:214-602-6900
Practice Address - Street 1:17330 PRESTON RD
Practice Address - Street 2:STE. 200D
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5997
Practice Address - Country:US
Practice Address - Phone:469-285-2530
Practice Address - Fax:214-602-6900
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4489101YP2500X
TX75801101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1939846Medicaid