Provider Demographics
NPI:1083820070
Name:VANCE, MARY MARTHA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MARTHA
Last Name:VANCE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11651 RIVER OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-2836
Mailing Address - Country:US
Mailing Address - Phone:512-585-7317
Mailing Address - Fax:
Practice Address - Street 1:100A W DEAN KEETON ST
Practice Address - Street 2:1 UNIVERSITY STATION A3500
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1002
Practice Address - Country:US
Practice Address - Phone:512-475-6938
Practice Address - Fax:512-471-8875
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32564103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist