=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861187254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA KEPPLE MA, LPA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2023
-----------------------------------------------------
Last Update Date | 04/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23035 S WATERLILY DR
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77406-8623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-368-9386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23035 S WATERLILY DR
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77406-8623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 39794
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------