Provider Demographics
NPI:1184268773
Name:MCCOY MANCE, OTHEA
Entity type:Individual
Prefix:
First Name:OTHEA
Middle Name:
Last Name:MCCOY MANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OTHEA
Other - Middle Name:
Other - Last Name:MCCOY MANCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:101 FEU FOLLET RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4234
Mailing Address - Country:US
Mailing Address - Phone:713-686-9194
Mailing Address - Fax:713-686-9413
Practice Address - Street 1:4411 DACOMA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-8611
Practice Address - Country:US
Practice Address - Phone:713-686-9194
Practice Address - Fax:713-686-9413
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX315121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX408994801Medicaid