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General NPI Number Information
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NPI Number | 1740928027
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Entity Type | Organization
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Legal Business Name | MYSTIC MAZE THERAPY AND CONSULTATION, PLLC
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Dates
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Enumeration Date | 05/25/2022
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Last Update Date | 08/08/2022
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Provider Practice Location Address
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Address Line | 1411 TAPERWICKE DR
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City | DALLAS
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State | TX
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Zip | 75232-4609
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Country | US
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Telephone | 469-542-0463
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Fax |
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Provider Business Mailing Address
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Address Line | 722 OAKBLUFF DR
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City | LANCASTER
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State | TX
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Zip | 75146-1429
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Country | US
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Telephone | 469-542-0463
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Fax |
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Authorized Official
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Title or Position | OWNER/SUPERVISOR
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Name | VERONICA FRAZIER
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Credential | LMFT, LPC
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Telephone | 469-542-0463
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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