Healthcare Provider Details

I. General information

NPI: 1780177832
Provider Name (Legal Business Name): MARY VIXAISACK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 GOLDEN GROVE DR
LEWISVILLE TX
75067-6118
US

IV. Provider business mailing address

937 GOLDEN GROVE DR
LEWISVILLE TX
75067-6118
US

V. Phone/Fax

Practice location:
  • Phone: 214-566-8777
  • Fax:
Mailing address:
  • Phone: 214-566-8777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number71432
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: