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General NPI Number Information
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NPI Number | 1174445506
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Entity Type | Organization
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Legal Business Name | ICEBREAKER THERAPY PLLC
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Dates
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Enumeration Date | 07/28/2026
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Last Update Date | 07/28/2026
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Provider Practice Location Address
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Address Line | 407 AUBURN PINES DR
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City | MONTGOMERY
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State | TX
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Zip | 77316-1955
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Country | US
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Telephone | 989-955-2026
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Fax |
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Provider Business Mailing Address
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Address Line | 5900 BALCONES DR STE 100
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City | AUSTIN
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State | TX
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Zip | 78731-4298
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Country | US
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Telephone | 989-955-2026
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MS. CARMEN R MERRILL
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Credential | LCSW
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Telephone | 989-955-2026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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