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General NPI Number Information
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NPI Number | 1659719615
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Entity Type | Organization
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Legal Business Name | MY OWN COUNSELOR
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Dates
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Enumeration Date | 06/11/2013
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Last Update Date | 06/11/2013
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Provider Practice Location Address
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Address Line | 1101 RIDGE RD 102
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City | ROCKWALL
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State | TX
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Zip | 75087-4250
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Country | US
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Telephone | 469-877-6190
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Fax |
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Provider Business Mailing Address
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Address Line | 1101 RIDGE RD 102
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City | ROCKWALL
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State | TX
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Zip | 75087-4250
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Country | US
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Telephone | 469-877-6190
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | CONNIE PETTITT
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Credential | LPC
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Telephone | 469-877-6190
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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 | 68526
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License Number State | TX
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