=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447439807
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISE MARIE MEDEROS M.A., LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2007
-----------------------------------------------------
Last Update Date | 05/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3815 LISBON ST SUITE 202
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-841-9110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2016 THOMAS PL
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-3941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-851-2594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 60605
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------