=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275366890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE REAL HEAL COLLECTIVE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2024
-----------------------------------------------------
Last Update Date | 08/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 PACIFIC AVE STE 2000
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75201-4540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-354-0119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1910 PACIFIC AVE SUITE 2000 PMB 1953
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75201-4520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | DR. AZURE CHAELYN SMITH-SWAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 214-354-0119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------