=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487202792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LESTON UNDERWOOD COUNSELING SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2019
-----------------------------------------------------
Last Update Date | 08/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6010 W SPRING CREEK PKWY # 245
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-3569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-896-9696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3615 FOXBORO LN
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-896-9696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | LESTON MARSHALL UNDERWOOD
-----------------------------------------------------
Credential | M.ED., LPC
-----------------------------------------------------
Telephone | 972-896-9696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------