MEDICARE: MYSTIC MAZE THERAPY AND CONSULTATION, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1740928027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYSTIC MAZE THERAPY AND CONSULTATION, PLLC

Provider Business Mailing Address
First Line	:	722 OAKBLUFF DR
Second Line	:
City	:	LANCASTER
State	:	TX
Zip	:	75146-1429
Country	:	US
Telephone Number	:	469-542-0463
Fax Number	:

Provider Business Practice Location Address
First Line	:	1411 TAPERWICKE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75232-4609
Country	:	US
Telephone Number	:	469-542-0463
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SUPERVISOR
Name	:	VERONICA FRAZIER
Credential	:	LMFT, LPC
Telephone Number	:	469-542-0463

Provider Enumeration Date	:	05/25/2022
Last Update Date	:	08/08/2022

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