=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477928844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE AUSTIN PSYCHOTHERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2015
-----------------------------------------------------
Last Update Date | 12/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 BEECAVE WOODS DR 208
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746-6762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-957-0951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 BEECAVE WOODS DR 208
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746-6762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEREMY H EZELL
-----------------------------------------------------
Credential | LPC-S
-----------------------------------------------------
Telephone | 214-957-0951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 65384
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------