Provider Demographics
NPI:1780010694
Name:TAYLOR, MARY LAUREN (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAUREN
Last Name:TAYLOR
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 1:6316 DOWNEAST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4120
Mailing Address - Country:US
Mailing Address - Phone:817-658-3485
Mailing Address - Fax:
Practice Address - Street 1:4200 KELLER HASLET RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8007
Practice Address - Country:US
Practice Address - Phone:817-431-1544
Practice Address - Fax:817-337-1328
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67519101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health