Individual
MARIE MACARAEG KOFNOVEC
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
630 STONEGLEN DR STE B, KELLER, TX 76248-3626
(817) 734-6515
(817) 717-8584
Mailing address
5724 HUNTERS BEND LN, DALLAS, TX 75249-2303
(972) 408-7012
Taxonomy
Speciality
Code
Description
License number
State
2080P0008X
Pediatric Neurodevelopmental Disabilities Physician
Primary
224Z00000X
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
464765
COTA
TX
Enumeration date
11/22/2021
Last updated
11/22/2021
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