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General NPI Number Information
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NPI Number | 1730635053
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Entity Type | Organization
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Legal Business Name | MINDSPROUTS PERSONAL GROWTH THERAPY PLLC
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Dates
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Enumeration Date | 08/28/2016
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Last Update Date | 03/01/2021
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Provider Practice Location Address
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Address Line | 16135 PRESTON RD STE 116
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City | DALLAS
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State | TX
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Zip | 75248-8532
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Country | US
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Telephone | 214-830-9879
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 863842
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City | PLANO
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State | TX
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Zip | 75086-3842
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Country | US
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Telephone | 214-830-9879
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST/OWNER
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Name | DR. CONNIE M SICILIANO AVILA
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Credential | PHD
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Telephone | 214-830-9879
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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 | 63226
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 37241
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License Number State | TX
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