=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245647379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY CARMEN THOMAS LPC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2014
-----------------------------------------------------
Last Update Date | 07/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 W NOLANA AVE # C
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-627-2487
-----------------------------------------------------
Fax | 956-627-3528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 W NOLANA AVE # C
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-627-2487
-----------------------------------------------------
Fax | 956-627-3528
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR/MANAGING MEMBER
-----------------------------------------------------
Name | MRS. MARY CARMEN STIVALET-THOMAS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 956-627-2487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 68345
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------