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General NPI Number Information
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NPI Number | 1205209756
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Entity Type | Organization
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Legal Business Name | WHOLESOME INTIMACY PLLC
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Dates
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Enumeration Date | 11/05/2015
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Last Update Date | 01/12/2017
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Provider Practice Location Address
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Address Line | 600 STRADA CIR SUITE 112
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City | MANSFIELD
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State | TX
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Zip | 76063-3201
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Country | US
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Telephone | 817-456-4893
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1138
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City | MANSFIELD
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State | TX
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Zip | 76063-1138
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Country | US
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Telephone | 817-456-4893
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. LILA J STEPHENSON
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Credential | MA, LPC, CST
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Telephone | 817-456-4893
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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