Provider Demographics
NPI:1639421894
Name:WEBB, MARY JEAN
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:JEAN
Last Name:WEBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 CANYON RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-3010
Mailing Address - Country:US
Mailing Address - Phone:682-232-6560
Mailing Address - Fax:
Practice Address - Street 1:3516 CANYON RIDGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3010
Practice Address - Country:US
Practice Address - Phone:682-232-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320600000X320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities