Provider Demographics
NPI:1386879906
Name:CHEN, MARY (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CHEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 OAK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759
Mailing Address - Country:US
Mailing Address - Phone:512-963-0348
Mailing Address - Fax:
Practice Address - Street 1:14619 SW TEAL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-6194
Practice Address - Country:US
Practice Address - Phone:512-963-0348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01121171100000X
ORAC152969171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist