Mary Lee Foundation

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

License

115787 Issued in TX

Legal business name

MARY LEE FOUNDATION

Practice address

1336 Lamar Square Dr
Suite a
Austin, TX 78704-2214

Phone

(512) 442-6077

Fax

(512) 442-6825

NPI assigned

Jun 1, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Don Lilljedahl, LSW

Title

Director of Founation

Phone

(512) 443-5777

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063614022. Details of each certification follow.

• CCN 45G144 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 45G144

Legal name

MARY LEE FOUNDATION SOUTHPOINTE I I

Certification status

Active

Provider type (POS)

Intermediate care facility for individuals with intellectual disabilities

Participating since

Nov 3, 1983

Last certification

Jan 24, 2025

Beds

13

Ownership / control type

Private (non-profit)

Facility address

1336 Lamar Square Dr
Austin, TX 78704

Tax ID family

Mary Lee Foundation3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• Mary Lee Foundation

  • Clinic/Center
  • Austin, TX
  • NPI 1083870778
  NPD tax ID
• Mary Lee Foundation

  • Assisted Living Facility (Mental Illness)
  • Austin, TX
  • NPI 1124209937
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1180656000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1063614022",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3174",
            "city": "AUSTIN",
            "state": "TX",
            "postal_code": "787643174",
            "telephone_number": "512-443-5777",
            "fax_number": "512-444-9949"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1336 LAMAR SQUARE DR",
            "address_2": "SUITE A",
            "city": "AUSTIN",
            "state": "TX",
            "postal_code": "787042214",
            "telephone_number": "512-442-6077",
            "fax_number": "512-442-6825"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARY LEE FOUNDATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "LILLJEDAHL",
        "authorized_official_first_name": "DON",
        "authorized_official_title_or_position": "DIRECTOR OF FOUNATION",
        "authorized_official_telephone_number": "512-443-5777",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "LSW"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "TX",
            "license": "115796",
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "TX",
            "license": "114956",
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "TX",
            "license": "115787",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRS CONTRACT",
            "identifier": "23346482 993",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Holly Maruscak, NP
• Katy Marvel, LCSW
• Jasmine Marwan
• Mary a. Gonzales, M.D., P.a.
• Mary Kate Peters, DDS, PLLC
• Mary Lee Foundation
• Mary Lee Foundation
• Mary Marvin Johnson,MD,PA,Dba (Northwest Pediatrics and Adolescents)
• Mary V. Mirto, D.O., P.a.
• Mary Webb-Tafoya PLLC

• Community/Behavioral Health Agency in Austin, TX
• Providers in Austin, TX by specialty
• Community/Behavioral Health Agency in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.