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Southlake, Texas

Provider NPI: 1366441578

Provider Information:
Gender: F
Sole Proprietor

Practice Location:
Tel: 940-224-0105  Fax: 817-488-9656

Business Mailing Address:
Tel: 940-224-0105  Fax: 817-488-9656

Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y101Y00000XBehavioral Health & Social Service Providers

Other Provider Identifiers:

Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin


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