Basic Information
| Provider Information | |||||||||
| NPI: | 1972599033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | ACSW, LMSW-ACP, LCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12850 HILLCREST RD | ||||||||
| Address2: | SUITE F-206 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752301529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724048253 | ||||||||
| FaxNumber: | 9727010874 | ||||||||
| Practice Location | |||||||||
| Address1: | 12850 HILLCREST RD | ||||||||
| Address2: | SUITE F-206 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752301529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724048253 | ||||||||
| FaxNumber: | 9727010874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2443 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 86514Q | 01 | TX | BCBS | OTHER |