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General NPI Number Information
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NPI Number | 1891142063
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Entity Type | Organization
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Legal Business Name | MIND ABOVE MATTER
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Dates
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Enumeration Date | 05/18/2016
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Last Update Date | 05/19/2016
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Provider Practice Location Address
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Address Line | 2915 S BURLESON BLVD
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City | BURLESON
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State | TX
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Zip | 76028-1878
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Country | US
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Telephone | 817-447-3001
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Fax |
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Provider Business Mailing Address
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Address Line | 4232 HERITAGE TRACE PKWY
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City | FORT WORTH
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State | TX
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Zip | 76244-5375
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BUSINESS OFFICE DIRECTOR
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Name | MISTY MOLINA
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Credential |
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Telephone | 817-447-3001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 72179
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License Number State | TX
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