=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093412231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY MELODY BOCKHOLT LMFT-ASSOCIATE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2023
-----------------------------------------------------
Last Update Date | 02/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 WESTBANK DR., STE 6-250
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-815-3599
-----------------------------------------------------
Fax | 737-237-5657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 WESTBANK DR., STE 6-250
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-815-3599
-----------------------------------------------------
Fax | 737-237-5657
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 204956
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------