Healthcare Provider Details

I. General information

NPI: 1851314157
Provider Name (Legal Business Name): MARILYN JEAN VACHE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 JEFFERSON ST STE 206
AUSTIN TX
78731-6225
US

IV. Provider business mailing address

3724 JEFFERSON ST STE 206
AUSTIN TX
78731
US

V. Phone/Fax

Practice location:
  • Phone: 512-458-1000
  • Fax: 512-458-1002
Mailing address:
  • Phone: 512-458-1000
  • Fax: 512-458-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberF3366
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number23152
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC39289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: