=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366258972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCENIC ROUTE WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2024
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 PITCHFORK TRL STE 921
-----------------------------------------------------
City | WILLOW PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76087-3281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-213-6734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 S OAKRIDGE DR STE 101
-----------------------------------------------------
City | HUDSON OAKS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76087-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-987-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | BRITTANY KIRK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 512-987-8840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------