Provider Demographics
NPI:1215576574
Name:TABOR, MARY KEMP (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KEMP
Last Name:TABOR
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 1:4656 HALLMARK DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-2940
Mailing Address - Country:US
Mailing Address - Phone:214-478-1304
Mailing Address - Fax:
Practice Address - Street 1:14114 DALLAS PKWY STE 245
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-1331
Practice Address - Country:US
Practice Address - Phone:214-478-1304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13090101YA0400X
TX76517101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)