Provider Demographics
NPI:1700145638
Name:ANTHONY, MARA-LYSA (PSYD)
Entity Type:Individual
Prefix:
First Name:MARA-LYSA
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MARA-LYSA
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1006 N BOWEN RD
Mailing Address - Street 2:105
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1006 N BOWEN RD
Practice Address - Street 2:105
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2826
Practice Address - Country:US
Practice Address - Phone:817-543-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-12
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36136103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist