Basic Information
| Provider Information | |||||||||
| NPI: | 1134728421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEACH | ||||||||
| FirstName: | MARLON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629 LOXLEY LN | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761311470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176835082 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16160 MIDWAY RD STE 218 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696803500 | ||||||||
| FaxNumber: | 9724268309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810007266 | VA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 38811 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.