Healthcare Provider Details

I. General information

NPI: 1245386457
Provider Name (Legal Business Name): MARY LOU SHACKLETON MA, LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15700 SPACE CENTER BLVD
HOUSTON TX
77062
US

IV. Provider business mailing address

PO BOX 590344
HOUSTON TX
77259-0344
US

V. Phone/Fax

Practice location:
  • Phone: 281-250-1724
  • Fax:
Mailing address:
  • Phone: 281-250-1724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number19271
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number5140
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: