Provider Demographics
NPI:1851694137
Name:BESTANI, MARY ELLEN (LICAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:BESTANI
Suffix:
Gender:F
Credentials:LICAC
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 1438
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL BEACH
Mailing Address - State:TX
Mailing Address - Zip Code:77650-1438
Mailing Address - Country:US
Mailing Address - Phone:409-225-2625
Mailing Address - Fax:409-762-6464
Practice Address - Street 1:957 GULF RD
Practice Address - Street 2:
Practice Address - City:CRYSTAL BEACH
Practice Address - State:TX
Practice Address - Zip Code:77650
Practice Address - Country:US
Practice Address - Phone:409-225-2625
Practice Address - Fax:409-762-6464
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00615171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist