Provider Demographics
NPI:1902154461
Name:MY FAMILY THERAPY
Entity Type:Organization
Organization Name:MY FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NERICCIO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD-CCC-SLP
Authorized Official - Phone:512-853-9864
Mailing Address - Street 1:6800 W GATE BLVD # 132-617
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-4883
Mailing Address - Country:US
Mailing Address - Phone:512-853-9864
Mailing Address - Fax:866-586-3938
Practice Address - Street 1:8700 MANCHACA RD STE 101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5372
Practice Address - Country:US
Practice Address - Phone:512-853-9864
Practice Address - Fax:866-586-3938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10310235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191681904Medicaid