Healthcare Provider Details

I. General information

NPI: 1255144861
Provider Name (Legal Business Name): ORIGINS SPI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11777 LEBANON RD
FRISCO TX
75035-6295
US

IV. Provider business mailing address

11777 LEBANON RD
FRISCO TX
75035-6295
US

V. Phone/Fax

Practice location:
  • Phone: 469-827-0000
  • Fax:
Mailing address:
  • Phone: 817-721-2372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: HILARY HOLLINGSWORTH SOJOURNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 817-721-2372