Provider Demographics
NPI:1275307266
Name:ST. MARY'S PLACE, LLC
Entity Type:Organization
Organization Name:ST. MARY'S PLACE, LLC
Other - Org Name:VOCATIONAL LIVING CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:CELESTE
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LCDC, LSOTP
Authorized Official - Phone:832-894-9359
Mailing Address - Street 1:PO BOX 1838
Mailing Address - Street 2:
Mailing Address - City:ALIEF
Mailing Address - State:TX
Mailing Address - Zip Code:77411-1838
Mailing Address - Country:US
Mailing Address - Phone:832-894-9359
Mailing Address - Fax:
Practice Address - Street 1:3707 CYPRESS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77068-3526
Practice Address - Country:US
Practice Address - Phone:832-894-9359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care AgencyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4173981-02Medicaid
TX4173981-01Medicaid