=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205331402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDI LEE URBAN M.ED., LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2018
-----------------------------------------------------
Last Update Date | 03/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 N PARIS ST
-----------------------------------------------------
City | MEXIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76667-2843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-307-1748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 LCR 762
-----------------------------------------------------
City | GROESBECK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76642-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-315-1657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 74110
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------