Provider Demographics
NPI:1598788010
Name:SORRELS, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SORRELS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3548
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78764-3548
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:512-440-4059
Practice Address - Street 1:1643 E 2ND ST
Practice Address - Street 2:BUILDING C
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4411
Practice Address - Country:US
Practice Address - Phone:512-445-7787
Practice Address - Fax:512-440-4059
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX294431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149084901Medicaid
TX00P336Medicare Oscar/Certification
TX149084901Medicaid