Provider Demographics
NPI:1427236876
Name:WENCESLAO, MARY ANNE MILLARE (LMSW, LCDC)
Entity type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:MILLARE
Last Name:WENCESLAO
Suffix:
Gender:F
Credentials:LMSW, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-472-4357
Mailing Address - Fax:
Practice Address - Street 1:1430 COLLIER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-2911
Practice Address - Country:US
Practice Address - Phone:512-472-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51086104100000X
TX10883101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker