Provider Demographics
NPI:1548690563
Name:NEWMAN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NEWMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7199 RENDON BLOODWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4925
Mailing Address - Country:US
Mailing Address - Phone:817-808-7172
Mailing Address - Fax:817-483-1294
Practice Address - Street 1:7199 RENDON BLOODWORTH RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4925
Practice Address - Country:US
Practice Address - Phone:817-808-7172
Practice Address - Fax:817-483-1294
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136646320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5646500178Medicaid