Provider Demographics
NPI:1932501251
Name:VADAKEKALAM, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VADAKEKALAM
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 1:307 BENTLEY MNR
Mailing Address - Street 2:
Mailing Address - City:SHAVANO PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1636 LOCKHILL SELMA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1929
Practice Address - Country:US
Practice Address - Phone:210-541-8455
Practice Address - Fax:210-541-9477
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
TX101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist