Provider Demographics
NPI:1841637881
Name:BEAVER, MARY AMANDA (PSY,D, LPC-S, NCC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:AMANDA
Last Name:BEAVER
Suffix:
Gender:F
Credentials:PSY,D, LPC-S, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 SCOTT AVE STE 630
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-2610
Mailing Address - Country:US
Mailing Address - Phone:940-202-0733
Mailing Address - Fax:940-232-9353
Practice Address - Street 1:2110 KEMP BLVD STE B
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4349
Practice Address - Country:US
Practice Address - Phone:940-285-2518
Practice Address - Fax:940-232-9353
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3192510-01Medicaid