Provider Demographics
NPI:1578255014
Name:MCBRIDE, MARY ALLEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALLEN
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BOWEN
Other - Last Name:MCBRIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:940 EBENEZER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-573-2617
Mailing Address - Fax:
Practice Address - Street 1:940 EBENEZER BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6002
Practice Address - Country:US
Practice Address - Phone:601-790-0583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2985101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor