=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174756795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ON DECK COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2009
-----------------------------------------------------
Last Update Date | 09/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 CARDINAL RIDGE RD
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-4960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-581-4730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 CARDINAL RIDGE RD
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-4960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-581-4730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPC
-----------------------------------------------------
Name | MRS. IRIS L KUYKENDALL
-----------------------------------------------------
Credential | MS, LPC, CRC
-----------------------------------------------------
Telephone | 817-581-4730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 60678
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------