=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861147886
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLA G JANECKA LPC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2022
-----------------------------------------------------
Last Update Date | 02/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 S KIMBALL AVE
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-1523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-946-4433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2711 COUNTRY GLEN CT
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-946-4433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number | 88010
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 88010
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------