Provider Demographics
NPI:1942527395
Name:DASH, MARY LEE (COUNSELOR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:DASH
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LEE
Other - Last Name:DASH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CADC-
Mailing Address - Street 1:1304 POLK ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-4542
Mailing Address - Country:US
Mailing Address - Phone:580-477-0824
Mailing Address - Fax:
Practice Address - Street 1:1304 POLK ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-4542
Practice Address - Country:US
Practice Address - Phone:580-477-0824
Practice Address - Fax:580-477-0984
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK156101YA0400X
TX9458101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)