Healthcare Provider Details

I. General information

NPI: 1831552645
Provider Name (Legal Business Name): LIFE TREE COUNSELING CENTER INCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14679 MIDWAY RD STE 200
ADDISON TX
75001-3196
US

IV. Provider business mailing address

14679 MIDWAY RD STE 200
ADDISON TX
75001-3196
US

V. Phone/Fax

Practice location:
  • Phone: 972-234-6634
  • Fax: 972-234-6648
Mailing address:
  • Phone: 972-234-6634
  • Fax: 972-234-6648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number75436
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number75436
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number75436
License Number StateTX

VIII. Authorized Official

Name: MRS. KATHLEEN MILLS
Title or Position: OWNER
Credential: LPC-S, CEAP
Phone: 972-234-6634