Provider Demographics
NPI:1275965667
Name:MARY JANE NATIVIDAD PROFESSIONAL COUNSELING PC
Entity Type:Organization
Organization Name:MARY JANE NATIVIDAD PROFESSIONAL COUNSELING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NATIVIDAD
Authorized Official - Suffix:
Authorized Official - Credentials:MED, NCC, LPC
Authorized Official - Phone:210-325-6874
Mailing Address - Street 1:3211 SHOSHONI RISE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2705
Mailing Address - Country:US
Mailing Address - Phone:210-325-6874
Mailing Address - Fax:830-438-3324
Practice Address - Street 1:3211 SHOSHONI RISE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78261-2705
Practice Address - Country:US
Practice Address - Phone:210-325-6874
Practice Address - Fax:830-438-3324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19403101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178701201Medicaid