Provider Demographics
NPI:1578785663
Name:COSTAS, MARY BASSETT (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BASSETT
Last Name:COSTAS
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 1:3815 LISBON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5601
Mailing Address - Country:US
Mailing Address - Phone:817-738-4660
Mailing Address - Fax:817-738-4773
Practice Address - Street 1:3815 LISBON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5601
Practice Address - Country:US
Practice Address - Phone:817-738-4660
Practice Address - Fax:817-738-4773
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11965101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional