MEDICARE: MARY M CLARKSON LPC

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	101YM0800X	Mental Health Counselor	LPC009671	GA
2	101YP2500X	Professional Counselor	65321	TX

General Provider Information

NPI Number	:	1417291253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY M CLARKSON LPC

Provider Business Mailing Address
First Line	:	3016 CULVERTON CT
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-6122
Country	:	US
Telephone Number	:	936-641-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	17163 BEAVER SPRINGS DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-2345
Country	:	US
Telephone Number	:	936-641-2700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2012
Last Update Date	:	11/14/2022

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