=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063067676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER KWESIE LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2019
-----------------------------------------------------
Last Update Date | 03/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 704 E 15TH ST STE 205
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75074-5712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-763-5843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4404 COLDBROOK LN
-----------------------------------------------------
City | SACHSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75048-4572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-455-8738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 73167
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------