=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326708819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRESH JOURNEY COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2021
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2312 WESTERN TRAILS BLVD # 204
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-1642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-658-5078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5180 W HIGHWAY 290 UNIT 150
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78735-8910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-842-9876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSANA MEJIA HERNANDEZ
-----------------------------------------------------
Credential | LICENSE PROFESSIONAL
-----------------------------------------------------
Telephone | 209-658-5078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------