Individual
DR. MARIETTA BACCUS RICHARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D
Contact information
Practice address
1725 E SOUTHLAKE BLVD STE 102, SOUTHLAKE, TX 76092-6457
(682) 477-4400
Mailing address
1725 E SOUTHLAKE BLVD STE 102, SOUTHLAKE, TX 76092-6457
(682) 477-4400
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
24396
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8K4637
DOCS MCR
TX
01
—
8K4700
DOMHA MCR
TX
Enumeration date
01/08/2008
Last updated
06/28/2019
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