=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588493324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTED LIFE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2024
-----------------------------------------------------
Last Update Date | 07/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2046 BEDFORD RD
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76021-5709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-726-9032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1116 CREST BREEZE DR
-----------------------------------------------------
City | HASLET
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76052-6149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-715-9869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MR. CARLTON ALAN VANCE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 817-715-9869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------