Provider Demographics
NPI:1619745205
Name:WILSON-SHALER, MARY EUVETTE (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EUVETTE
Last Name:WILSON-SHALER
Suffix:
Gender:F
Credentials:LMT
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 1246
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:78362-1246
Mailing Address - Country:US
Mailing Address - Phone:361-563-3578
Mailing Address - Fax:
Practice Address - Street 1:2001 S STAPLES ST STE 100
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-3000
Practice Address - Country:US
Practice Address - Phone:361-741-0838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT014540225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist