Healthcare Provider Details

I. General information

NPI: 1750905576
Provider Name (Legal Business Name): MARIANA CASTLE AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 8TH AVE
FORT WORTH TX
76110-1349
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-4063
  • Fax: 682-885-1878
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number81136
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: