Basic Information
| Provider Information | |||||||||
| NPI: | 1548561525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2806 HIGHWAY 35 N | ||||||||
| Address2: | |||||||||
| City: | ROCKPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783825711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617270143 | ||||||||
| FaxNumber: | 3617272036 | ||||||||
| Practice Location | |||||||||
| Address1: | 2806 HIGHWAY 35 N | ||||||||
| Address2: | |||||||||
| City: | ROCKPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783825711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617270143 | ||||||||
| FaxNumber: | 3617272036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2010 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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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 | 66814 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 2887010 | 05 | TX | MEDICAID |