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General NPI Number Information
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NPI Number | 1932874633
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Entity Type | Organization
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Legal Business Name | RITUAL WELLNESS ATX PLLC
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Dates
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Enumeration Date | 08/13/2021
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Last Update Date | 09/16/2021
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Provider Practice Location Address
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Address Line | 4131 SPICEWOOD SPRINGS RD STE I7
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City | AUSTIN
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State | TX
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Zip | 78759-8659
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Country | US
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Telephone | 903-914-0224
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 170073
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City | AUSTIN
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State | TX
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Zip | 78717-0004
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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 | LICENSED PSYCHOLOGIST
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Name | DR. SHANNON LEIGH STAVINOHA
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Credential | PHD
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Telephone | 903-914-0224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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