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General NPI Number Information
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NPI Number | 1154580538
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Entity Type | Organization
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Legal Business Name | MIND SPA INC
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Dates
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Enumeration Date | 06/02/2008
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Last Update Date | 03/07/2012
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Provider Practice Location Address
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Address Line | 1801 N HAMPTON RD STE 410
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City | DESOTO
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State | TX
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Zip | 75115-2338
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Country | US
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Telephone | 972-780-5160
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Fax | 972-780-5735
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Provider Business Mailing Address
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Address Line | 1801 N HAMPTON RD STE 410
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City | DESOTO
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State | TX
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Zip | 75115-2338
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Country | US
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Telephone | 972-780-5160
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Fax |
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | PROF. LARRY GROVER WASHINGTON
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Credential | M.S.
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Telephone | 972-780-5160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 19695
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License Number State | TX
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