=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962665356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELTON DAVID WOOLSEY LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2008
-----------------------------------------------------
Last Update Date | 07/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 MANCHACA RD SUITE 202
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704-6631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-517-8960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 KREBS LN
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704-7075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-443-1583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 62667
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------