Provider Demographics
NPI:1063719904
Name:KING, MARY
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 SNOW RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-3160
Mailing Address - Country:US
Mailing Address - Phone:817-648-9298
Mailing Address - Fax:
Practice Address - Street 1:6308 SNOW RIDGE CT
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-3160
Practice Address - Country:US
Practice Address - Phone:817-648-9298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
TX71646101YM0800X, 101YA0400X, 101Y00000X, 101YP2500X, 106H00000X, 101YS0200X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352705301Medicaid
TX840LQBOtherBLUE CROSS BLUE SHIELD
TX352705302Medicaid