Provider Demographics
NPI:1225420995
Name:SPELLMAN, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SPELLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:SPELLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:515 N SAM HOUSTON PKWY E STE 215
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-4000
Mailing Address - Country:US
Mailing Address - Phone:281-578-1205
Mailing Address - Fax:281-931-4429
Practice Address - Street 1:515 N SAM HOUSTON PKWY E STE 215
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-4000
Practice Address - Country:US
Practice Address - Phone:281-578-1205
Practice Address - Fax:281-931-4429
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX695982171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095158402Medicaid
TX095158404Medicaid