Provider Demographics
NPI:1194460485
Name:GRANT, MAE MARIE (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:MARIE
Last Name:GRANT
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 WHITE IBIS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-8077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8717 WHITE IBIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-8077
Practice Address - Country:US
Practice Address - Phone:512-695-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1700516101YS0200X
TX82430101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool