MEDICARE: MARQUITTA J FIELDS S-MFT

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	2012022112	MO
2	106H00000X	Marriage & Family Therapist	2008018147	MO

General Provider Information

NPI Number	:	1730655150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARQUITTA J FIELDS S-MFT

Provider Business Mailing Address
First Line	:	12609 FOUNTAIN LAKE DR
Second Line	:
City	:	GRANDVIEW
State	:	MO
Zip	:	64030-1599
Country	:	US
Telephone Number	:	816-651-2214
Fax Number	:

Provider Business Practice Location Address
First Line	:	4110 BALTIMORE AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64111-2303
Country	:	US
Telephone Number	:	816-651-2214
Fax Number	:

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

Provider Enumeration Date	:	10/23/2018
Last Update Date	:	09/30/2019

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