Healthcare Provider Details

I. General information

NPI: 1053236448
Provider Name (Legal Business Name): CHARITY ELYSSA PACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 PEBBLEBROOK LN
GLENN HEIGHTS TX
75154-1851
US

IV. Provider business mailing address

2812 PACIFIC AVE
MIDLOTHIAN TX
76065-6778
US

V. Phone/Fax

Practice location:
  • Phone: 469-978-1318
  • Fax:
Mailing address:
  • Phone: 469-978-1318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number102556
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: