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General NPI Number Information
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NPI Number | 1407629470
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Entity Type | Organization
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Legal Business Name | ROSEBUD HERITAGE TRUST
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Dates
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Enumeration Date | 11/01/2023
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Last Update Date | 11/01/2023
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Provider Practice Location Address
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Address Line | 400 W OAK ST STE 313
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City | DENTON
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State | TX
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Zip | 76201-9092
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Country | US
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Telephone | 940-304-3054
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Fax |
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Provider Business Mailing Address
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Address Line | 152 CUNNINGHAM RD
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City | DENTON
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State | TX
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Zip | 76208-4130
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Country | US
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Telephone | 940-304-3054
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRISANN MAYFIELD
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Credential | LPC-S
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Telephone | 940-304-3054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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