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General NPI Number Information
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NPI Number | 1629610084
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Entity Type | Individual
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Provider Name | MITCHELL ISLE LPC
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Gender | Male
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Dates
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Enumeration Date | 10/16/2019
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Last Update Date | 10/16/2019
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Provider Practice Location Address
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Address Line | 12740 HILLCREST RD STE 270
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City | DALLAS
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State | TX
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Zip | 75230-2086
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Country | US
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Telephone | 469-712-5734
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Fax |
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Provider Business Mailing Address
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Address Line | 201 WILDWOOD PL
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City | ALLEN
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State | TX
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Zip | 75013-1501
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Country | US
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Telephone | 214-564-5348
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 70650
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License Number State | TX
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