=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851038863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMBODIED ART THERAPY AND COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8400 N MOPAC EXPY STE 301
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-8323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-503-5030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8400 N MOPAC EXPY STE 301
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-8323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ART THERAPIST AND COUNSELOR
-----------------------------------------------------
Name | MALLORY KATHLEEN KEEKS
-----------------------------------------------------
Credential | LPC, ATR
-----------------------------------------------------
Telephone | 512-503-5030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------