Healthcare Provider Details

I. General information

NPI: 1912509258
Provider Name (Legal Business Name): MARIAH RENEE EVERITT LPC-ASSOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E ANDERSON LN # 120
AUSTIN TX
78752-1236
US

IV. Provider business mailing address

193 LAKE GLN
SAN MARCOS TX
78666-8042
US

V. Phone/Fax

Practice location:
  • Phone: 512-961-5575
  • Fax:
Mailing address:
  • Phone: 281-382-8575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number84526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: