Provider Demographics
NPI:1588753925
Name:NATIVIDAD, MARY JANE (MED LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:NATIVIDAD
Suffix:
Gender:F
Credentials:MED LPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:LEYVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:7627 DERBY RUN
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-3936
Mailing Address - Country:US
Mailing Address - Phone:210-325-6874
Mailing Address - Fax:210-267-9072
Practice Address - Street 1:401 E SONTERRA BLVD STE 375
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4321
Practice Address - Country:US
Practice Address - Phone:210-325-6874
Practice Address - Fax:210-267-9072
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19403101YM0800X, 101Y00000X, 101YP2500X
TX101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXLBW61OtherMEDICAID PIN
TX178701201Medicaid
TX178701202Medicaid