MEDICARE: MARY VADAKEKALAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist
2	101YP2500X	Professional Counselor		TX

General Provider Information

NPI Number	:	1932501251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY VADAKEKALAM

Provider Business Mailing Address
First Line	:	307 BENTLEY MNR
Second Line	:
City	:	SHAVANO PARK
State	:	TX
Zip	:	78249-2021
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1636 LOCKHILL SELMA RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1929
Country	:	US
Telephone Number	:	210-541-8455
Fax Number	:	210-541-9477

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2014
Last Update Date	:	09/03/2021

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Directions to “ MARY VADAKEKALAM ” Practice Location

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