=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588446108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOURNEY TO GRACE COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2023
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 HWY 121 BYP STE A250
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75067-4183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 945-300-9788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4251 FM 2181 STE 230-174
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76210-4219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 945-300-9788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CORI RILEY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 945-300-9788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------