=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841640596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED VISION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2016
-----------------------------------------------------
Last Update Date | 07/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 N WATSON RD 289-B
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76006-6190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-752-4808
-----------------------------------------------------
Fax | 817-752-6022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 N WATSON RD 289-B
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76006-6190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / LPC
-----------------------------------------------------
Name | SIOBHAN DENISE FLOWERS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 817-752-4808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 70087
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------