=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194819813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY POMEROY PETTY LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1118 BARKDULL
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-447-0847
-----------------------------------------------------
Fax | 713-528-4579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 BISSONNET
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-528-2732
-----------------------------------------------------
Fax | 713-528-4579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 02573
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------