Healthcare Provider Details

I. General information

NPI: 1396470357
Provider Name (Legal Business Name): MARISELA SAMPLE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E FLORIDA AVE
MIDLAND TX
79701-8212
US

IV. Provider business mailing address

1409 LAGUNA MEADOWS TRL
MIDLAND TX
79705-2094
US

V. Phone/Fax

Practice location:
  • Phone: 432-685-0450
  • Fax:
Mailing address:
  • Phone: 432-559-8689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number80241
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: