Basic Information
| Provider Information | |||||||||
| NPI: | 1083870778 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY LEE FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MARY LEE FOUNDATION REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1328 LAMAR SQUARE DR. | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124431360 | ||||||||
| FaxNumber: | 5124431758 | ||||||||
| Practice Location | |||||||||
| Address1: | 1339 LAMAR SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124431360 | ||||||||
| FaxNumber: | 5124431758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2008 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRUMP | ||||||||
| AuthorizedOfficialFirstName: | CHARLENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5124435777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARY LEE FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.