Provider Demographics
NPI:1366794059
Name:MAYO, ALBERT E (PHD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:E
Last Name:MAYO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 PRATT RD
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-5228
Mailing Address - Country:US
Mailing Address - Phone:214-478-8379
Mailing Address - Fax:
Practice Address - Street 1:912 S. ERVAY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201
Practice Address - Country:US
Practice Address - Phone:214-478-8379
Practice Address - Fax:972-581-4313
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31003103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307679608Medicaid
TX307679609OtherMEDICAID CSHCN
TX89440AOtherBLUE CROSS BLUE SHIELD NUMBER
TX307679608Medicaid