MEDICARE: MARY LEE FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1083870778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY LEE FOUNDATION

Provider Business Mailing Address
First Line	:	1328 LAMAR SQUARE DR.
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704
Country	:	US
Telephone Number	:	512-443-1360
Fax Number	:	512-443-1758

Provider Business Practice Location Address
First Line	:	1339 LAMAR SQUARE DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704
Country	:	US
Telephone Number	:	512-443-1360
Fax Number	:	512-443-1758

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CHARLENE CRUMP
Credential	:
Telephone Number	:	512-443-5777

Provider Enumeration Date	:	08/01/2008
Last Update Date	:	02/25/2020

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Directions to “MARY LEE FOUNDATION ” Practice Location

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