Healthcare Provider Details

I. General information

NPI: 1578158317
Provider Name (Legal Business Name): MARY THACKER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 FM 2920 RD
SPRING TX
77388-3400
US

IV. Provider business mailing address

245 FM 1488 RD APT 1606
CONROE TX
77384-3953
US

V. Phone/Fax

Practice location:
  • Phone: 936-232-4557
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number81824
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: