=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134423577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASCENSION COUNSELING AND WELLNESS SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2010
-----------------------------------------------------
Last Update Date | 06/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 ROYAL CROWN RD
-----------------------------------------------------
City | HORIZON CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79928-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-227-4550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 ROYAL CROWN RD
-----------------------------------------------------
City | HORIZON CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79928-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-227-4550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MRS. MYRA LISETTE HERNANDEZ
-----------------------------------------------------
Credential | M.S., LPC
-----------------------------------------------------
Telephone | 915-227-4550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 16481
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------