{
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"FirstLineMailingAddress": "1810 8TH AVE",
"SecondLineMailingAddress": "SUITE B204, 2ND FLOOR",
"MailingAddressCityName": "FORT WORTH",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76110-1352",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "682-235-3401",
"MailingAddressFaxNumber": "413-208-3830",
"FirstLinePracticeLocationAddress": "1810 8TH AVE",
"SecondLinePracticeLocationAddress": "SUITE B204, 2ND FLOOR",
"PracticeLocationAddressCityName": "FORT WORTH",
"PracticeLocationAddressStateName": "TX",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "682-235-3401",
"PracticeLocationAddressFaxNumber": "413-208-3830",
"EnumerationDate": "06/14/2014",
"LastUpdateDate": "04/02/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DAINTY",
"AuthorizedOfficialFirstName": "MARY",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "COUNSELOR SUPERVISOR",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LPC-S",
"AuthorizedOfficialTelephoneNumber": "682-235-3401",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Professional Counselor",
"LicenseNumber": "18640",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}