Healthcare Provider Details

I. General information

NPI: 1407497050
Provider Name (Legal Business Name): WOVEN WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 KILLIAN DR
MANSFIELD TX
76063-6009
US

IV. Provider business mailing address

PO BOX 1469
KENNEDALE TX
76060-1469
US

V. Phone/Fax

Practice location:
  • Phone: 817-271-7508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LACEY EATON
Title or Position: OWNER
Credential: LPC
Phone: 817-271-7508