=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578988341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LJ PSYCHOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2014
-----------------------------------------------------
Last Update Date | 03/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1106 SANTA FE TRL STE 9
-----------------------------------------------------
City | DUNCANVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75137-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-600-5056
-----------------------------------------------------
Fax | 972-863-3263
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106 SANTA FE TRL STE 9
-----------------------------------------------------
City | DUNCANVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75137-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-600-5056
-----------------------------------------------------
Fax | 972-863-3263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OWNER
-----------------------------------------------------
Name | LYNDA JOHNSON
-----------------------------------------------------
Credential | LPC-S
-----------------------------------------------------
Telephone | 469-600-5056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 63935
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------