Provider Demographics
NPI:1356507586
Name:DOM, MARY ANN (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:DOM
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 1:8826 THATCH DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3714
Mailing Address - Country:US
Mailing Address - Phone:210-488-0384
Mailing Address - Fax:210-858-6657
Practice Address - Street 1:6502 BANDERA RD STE 202
Practice Address - Street 2:
Practice Address - City:LEON VALLEY
Practice Address - State:TX
Practice Address - Zip Code:78238-1454
Practice Address - Country:US
Practice Address - Phone:210-488-0384
Practice Address - Fax:210-941-0682
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12359101Y00000X, 101YA0400X, 101YM0800X, 106H00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095532004Medicaid