=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467256115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENMAZE TELEHEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2025
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23119 W IH-10 FRONTAGE RD, BLDG 10
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-926-5777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23119 W IH-10 FRONTAGE RD, BLDG 10
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-926-5777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LINDSAY ESSERY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-926-5777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------