Provider Demographics
NPI:1477762664
Name:DEAN, MARY R (LPC MHSP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:R
Last Name:DEAN
Suffix:
Gender:F
Credentials:LPC MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 POPLAR AVE
Mailing Address - Street 2:SUITE 515
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:US
Mailing Address - Phone:901-763-1288
Mailing Address - Fax:901-763-3334
Practice Address - Street 1:4515 POPLAR AVE
Practice Address - Street 2:SUITE 515
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117
Practice Address - Country:US
Practice Address - Phone:901-763-1288
Practice Address - Fax:901-763-3334
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4074543OtherBCBS