=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033771035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOURNEY TO DREAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2019
-----------------------------------------------------
Last Update Date | 07/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1960 ARCHER AVE
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75077-7602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-317-3935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1960 ARCHER AVE
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75077-7602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-317-3935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | D'ANDRALA ALEXANDER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 972-317-3935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------