Basic Information
| Provider Information | |||||||||
| NPI: | 1154443687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANCOCK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1553 E HARRY AVE | ||||||||
| Address2: | |||||||||
| City: | HAZEL PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480302159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487605301 | ||||||||
| FaxNumber: | 2486299903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N TELEGRAPH RD BLDG 32-E | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484561991 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401006948 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.