Basic Information
| Provider Information | |||||||||
| NPI: | 1124209937 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY LEE FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3174 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787643174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124431360 | ||||||||
| FaxNumber: | 5124431758 | ||||||||
| Practice Location | |||||||||
| Address1: | 1326 LAMAR SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787048970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124431360 | ||||||||
| FaxNumber: | 5124431758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2007 | ||||||||
| LastUpdateDate: | 11/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | CRUMP | ||||||||
| AuthorizedOfficialFirstName: | CHARLENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5124431360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0625X | 120677 | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
No ID Information.