Provider Demographics
NPI:1972720266
Name:WILSON, MARY GERALYN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GERALYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GERALYN
Other - Last Name:MAURER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:14340 TORREY CHASE BLVD
Mailing Address - Street 2:#160
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014-1021
Mailing Address - Country:US
Mailing Address - Phone:281-580-8086
Mailing Address - Fax:
Practice Address - Street 1:14340 TORREY CHASE BLVD
Practice Address - Street 2:#160
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-1021
Practice Address - Country:US
Practice Address - Phone:281-580-8086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15530101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional