Basic Information
| Provider Information | |||||||||
| NPI: | 1912479544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYMOND | ||||||||
| FirstName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 DIANA ST | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494311987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318456294 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 DIANA ST | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494311987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318456294 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2018 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401016428 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.