Healthcare Provider Details

I. General information

NPI: 1619317674
Provider Name (Legal Business Name): MARY KATHRINE RAE SUMO M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2013
Last Update Date: 07/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PEAR RIDGE DR 432
DALLAS TX
75287-5228
US

IV. Provider business mailing address

4500 PEAR RIDGE DR 432
DALLAS TX
75287-5228
US

V. Phone/Fax

Practice location:
  • Phone: 972-781-8086
  • Fax:
Mailing address:
  • Phone: 972-781-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number26084506
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: