MEDICARE: MR. MARSHAL DILLON MARTIN MAIWALD LMFT ASSOCIATE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	204843	TX

General Provider Information

NPI Number	:	1083323877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARSHAL DILLON MARTIN MAIWALD LMFT ASSOCIATE

Provider Business Mailing Address
First Line	:	1114 OAKWOOD DR
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76205-5940
Country	:	US
Telephone Number	:	703-789-1579
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 DALLAS DR
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76205-5100
Country	:	US
Telephone Number	:	940-483-1789
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2022
Last Update Date	:	11/21/2022

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