Provider Demographics
NPI:1619980497
Name:SPENCER, MARY ELLEN (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SPENCER
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 1:2220 HIGHWAY 35 N
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-3312
Mailing Address - Country:US
Mailing Address - Phone:361-790-8100
Mailing Address - Fax:512-727-6474
Practice Address - Street 1:2220 HIGHWAY 35 N
Practice Address - Street 2:SUITE 240
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3312
Practice Address - Country:US
Practice Address - Phone:361-790-8100
Practice Address - Fax:512-727-6474
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19379101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173556501Medicaid
TX7515LCOtherBLUE CROSS/BLUE SHIELD
TX261489OtherCOMPSYCH