Provider Demographics
NPI:1609247501
Name:KING, MARY LEE (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:KING
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 1:1664 KELLER PKWY
Mailing Address - Street 2:103
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3702
Mailing Address - Country:US
Mailing Address - Phone:817-381-6279
Mailing Address - Fax:
Practice Address - Street 1:1664 KELLER PKWY
Practice Address - Street 2:103
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3702
Practice Address - Country:US
Practice Address - Phone:817-381-6279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-18
Last Update Date:2015-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71424101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional