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General NPI Number Information
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NPI Number | 1124209937
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Entity Type | Organization
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Legal Business Name | MARY LEE FOUNDATION
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Dates
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Enumeration Date | 11/20/2007
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Last Update Date | 11/20/2007
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Provider Practice Location Address
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Address Line | 1326 LAMAR SQUARE DR
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City | AUSTIN
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State | TX
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Zip | 78704-8970
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Country | US
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Telephone | 512-443-1360
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Fax | 512-443-1758
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Provider Business Mailing Address
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Address Line | PO BOX 3174
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City | AUSTIN
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State | TX
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Zip | 78764-3174
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Country | US
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Telephone | 512-443-1360
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Fax | 512-443-1758
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. CHARLENE CRUMP
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Credential |
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Telephone | 512-443-1360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | 120677
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License Number State | TX
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