Provider Demographics
NPI:1629228622
Name:DUKE, MARY R (MED)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:DUKE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:R
Other - Last Name:ATIBURCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19419 BRIDGE OAK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3638
Mailing Address - Country:US
Mailing Address - Phone:808-214-3422
Mailing Address - Fax:
Practice Address - Street 1:19419 BRIDGE OAK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3638
Practice Address - Country:US
Practice Address - Phone:808-214-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX87048101YP2500X
HI268101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional