=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275270993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGASA CREATVE ARTS THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2022
-----------------------------------------------------
Last Update Date | 05/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5338 KIAMESHA WAY
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-510-3117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5338 KIAMESHA WAY
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-510-3117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. KEITA ONUMA
-----------------------------------------------------
Credential | MA, THM, MT-BC, LPC
-----------------------------------------------------
Telephone | 480-510-3117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------