Healthcare Provider Details

I. General information

NPI: 1265013395
Provider Name (Legal Business Name): BETH DESKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 11/05/2022
Certification Date: 11/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SOUTHTOWN DR
GRANBURY TX
76048-2682
US

IV. Provider business mailing address

4520 CONTRARY CREEK RD
GRANBURY TX
76048-6265
US

V. Phone/Fax

Practice location:
  • Phone: 855-579-5323
  • Fax:
Mailing address:
  • Phone: 817-559-4260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15808
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number86299
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: