=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225828452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAIRE MICHELLE BRORMAN LPC ASSOCIATE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2025
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 DALLAS DR STE 100
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76205-7289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-395-4455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9150 S COULTER ST APT 1423
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79119-5906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-670-5138
-----------------------------------------------------
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 | 98811
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------