MEDICARE: ORIGINS COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	261QM1300X	Multi-Specialty Clinic/Center
3	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1679116909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORIGINS COUNSELING LLC

Provider Business Mailing Address
First Line	:	4001 MAPLE AVE STE 300
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-3241
Country	:	US
Telephone Number	:	214-817-4964
Fax Number	:	210-634-3961

Provider Business Practice Location Address
First Line	:	12870 HILLCREST RD STE H226
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-1531
Country	:	US
Telephone Number	:	214-817-4964
Fax Number	:	210-634-3961

Authorized Official
Title or Position	:	DIRECTOR OF COMPLIANCE
Name	:	ANNA LISA DE LIMA
Credential	:
Telephone Number	:	561-201-8209

Provider Enumeration Date	:	10/18/2019
Last Update Date	:	10/30/2023

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