=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346942463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEVEN 11 THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2023
-----------------------------------------------------
Last Update Date | 03/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 641 CHRISTOPHER LN
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-997-1573
-----------------------------------------------------
Fax | 972-848-1733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 641 CHRISTOPHER LN
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-997-1573
-----------------------------------------------------
Fax | 972-848-1733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PIPER KISER
-----------------------------------------------------
Credential | MED
-----------------------------------------------------
Telephone | 972-997-1573
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------