Provider Demographics
NPI:1245386457
Name:SHACKLETON, MARY LOU (MA, LPC, LMFT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:SHACKLETON
Suffix:
Gender:F
Credentials:MA, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 590344
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77259-0344
Mailing Address - Country:US
Mailing Address - Phone:281-250-1724
Mailing Address - Fax:
Practice Address - Street 1:15700 SPACE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77062
Practice Address - Country:US
Practice Address - Phone:281-250-1724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19271101YM0800X
TX5140106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84558LOtherBLUECROSSINSURPROVIDER#