Provider Demographics
NPI:1740343078
Name:WEITZ, MARY K (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:WEITZ
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:MISS
Other - First Name:SABIHA
Other - Middle Name:MARY
Other - Last Name:WEITZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:615 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-2707
Mailing Address - Country:US
Mailing Address - Phone:254-215-2000
Mailing Address - Fax:
Practice Address - Street 1:4802 S 31ST ST
Practice Address - Street 2:APT. # 911
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-6208
Practice Address - Country:US
Practice Address - Phone:254-721-5338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0955080 SFX 01-05Medicaid