Healthcare Provider Details

I. General information

NPI: 1194638692
Provider Name (Legal Business Name): DIANA MAURICIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 BELT LINE RD STE 160
ADDISON TX
75001-5802
US

IV. Provider business mailing address

4006 BELT LINE RD STE 160
ADDISON TX
75001-5802
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number103922
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: