Provider Demographics
NPI:1487120127
Name:ELLISOR, MARY KEY (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KEY
Last Name:ELLISOR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 GREENHOUSE RD STE 10
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-6793
Mailing Address - Country:US
Mailing Address - Phone:832-779-1136
Mailing Address - Fax:
Practice Address - Street 1:3880 GREENHOUSE RD STE 10
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-6793
Practice Address - Country:US
Practice Address - Phone:832-779-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-21
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX834460OtherBCBS TEXAS