Healthcare Provider Details

I. General information

NPI: 1942788625
Provider Name (Legal Business Name): MARQUITA D ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N UNIVERSITY DR
FORT WORTH TX
76107-1360
US

IV. Provider business mailing address

100 N UNIVERSITY DR
FORT WORTH TX
76107-1360
US

V. Phone/Fax

Practice location:
  • Phone: 817-814-2000
  • Fax:
Mailing address:
  • Phone: 817-814-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number38918
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number116990
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: