=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639714504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALKING WITH WISDOM, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2019
-----------------------------------------------------
Last Update Date | 11/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 OAK LAWN AVE STE 720
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-4370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-288-2884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9465 SHERWOOD GLN
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-4129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-564-4149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | JENNIFER HENRY FURLONG
-----------------------------------------------------
Credential | LPC-S
-----------------------------------------------------
Telephone | 214-564-4149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------