Healthcare Provider Details

I. General information

NPI: 1982221115
Provider Name (Legal Business Name): ANDREA FACKLER LPC-INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 S. MOPAC EXPRESSWAY BUILDING 3, SUITE 503
AUSTIN TX
78735
US

IV. Provider business mailing address

3115 S 1ST ST APT 201
AUSTIN TX
78704-6365
US

V. Phone/Fax

Practice location:
  • Phone: 512-270-1513
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number83581
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: