Provider Demographics
NPI:1922423383
Name:HARRIS, MARY J (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JONI
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1610 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-1777
Mailing Address - Country:US
Mailing Address - Phone:682-367-8877
Mailing Address - Fax:
Practice Address - Street 1:2928 W 5TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-332-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65247101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX329574301Medicaid
811LPKOtherBLUE CROSS BLUE SHIELD