Healthcare Provider Details

I. General information

NPI: 1639236862
Provider Name (Legal Business Name): MARY ANNE MCKENYON L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 W. BETHEL RD. 100
COPPELL TX
75019-4474
US

IV. Provider business mailing address

413 W. BETHEL RD. 100
COPPELL TX
75019-4474
US

V. Phone/Fax

Practice location:
  • Phone: 972-393-1596
  • Fax: 972-304-0400
Mailing address:
  • Phone: 972-393-1596
  • Fax: 972-304-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10932
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: