=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316331572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPLY MINDFUL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2015
-----------------------------------------------------
Last Update Date | 03/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 LEANDER RD
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-8801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-587-6352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3403 DEER TRL
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | HEATHER CASSTEVENS MOELLER
-----------------------------------------------------
Credential | M.A.
-----------------------------------------------------
Telephone | 512-587-6352
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 70113
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------