=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629890694
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA ECKSTROM LPC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2024
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2770 MAIN ST STE 139
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-4357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-352-7491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2770 MAIN ST STE 139
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-4357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-352-7491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 94538
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------