Provider Demographics
NPI:1083763783
Name:CARRASCO, MARY J (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4232
Mailing Address - Country:US
Mailing Address - Phone:432-333-3667
Mailing Address - Fax:432-580-3115
Practice Address - Street 1:2445 E 11TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4232
Practice Address - Country:US
Practice Address - Phone:432-333-3667
Practice Address - Fax:432-580-3115
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62631101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional