=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669073037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEHOUSE PROFESSIONAL COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2020
-----------------------------------------------------
Last Update Date | 11/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6602 POLARIS DR STE 1
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-2082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-602-0117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6602 POLARIS DR. SUITE 1
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-2082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-285-4962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPC-S/ OWNER
-----------------------------------------------------
Name | MS. ROXANNA ALVAREZ
-----------------------------------------------------
Credential | LPC-S, CTRS
-----------------------------------------------------
Telephone | 956-602-0117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------