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	3104A0625X	Assisted Living Facility (Mental Illness)	120677	TX

General Provider Information

NPI Number	:	1124209937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY LEE FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 3174
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78764-3174
Country	:	US
Telephone Number	:	512-443-1360
Fax Number	:	512-443-1758

Provider Business Practice Location Address
First Line	:	1326 LAMAR SQUARE DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-8970
Country	:	US
Telephone Number	:	512-443-1360
Fax Number	:	512-443-1758

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. CHARLENE CRUMP
Credential	:
Telephone Number	:	512-443-1360

Provider Enumeration Date	:	11/20/2007
Last Update Date	:	11/20/2007

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