Provider Demographics
NPI:1124872775
Name:BRACKEN, MARY CLAIRE
Entity type:Individual
Prefix:
First Name:MARY CLAIRE
Middle Name:
Last Name:BRACKEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 W LOVERS LN STE 350
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-7106
Mailing Address - Country:US
Mailing Address - Phone:214-907-0772
Mailing Address - Fax:
Practice Address - Street 1:5757 W LOVERS LN STE 350
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-7106
Practice Address - Country:US
Practice Address - Phone:214-907-0772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-324662106S00000X
TX7775103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician