Provider Demographics
NPI:1174256879
Name:MAMMANO, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:MAMMANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TX
Mailing Address - Zip Code:75009-2825
Mailing Address - Country:US
Mailing Address - Phone:678-592-0820
Mailing Address - Fax:
Practice Address - Street 1:3074 FOREST DR
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TX
Practice Address - Zip Code:75009-2825
Practice Address - Country:US
Practice Address - Phone:678-592-0820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71489103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool