Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 8385 | TX |
NPI | 1003836743 |
---|---|
Provider Name | Mrs. Mary Magdalene Smith |
First Address | Dallas, TX 75247-4914 |
Second Address | Dallas, TX 75211-1655 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2006 |
Last Update Date | 15/07/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
174950901 | (05) | TX |