MEDICARE: MISS RETA KATHLEEN ELROD LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	62041	TX

General Provider Information

NPI Number	:	1184706210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS RETA KATHLEEN ELROD LPC

Provider Business Mailing Address
First Line	:	2901 BARTON SKWY APT 3312
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78746-7562
Country	:	US
Telephone Number	:	512-779-7101
Fax Number	:	512-494-0788

Provider Business Practice Location Address
First Line	:	1221 W BEN WHITE BLVD
Second Line	:	SUITE 108A
City	:	AUSTIN
State	:	TX
Zip	:	78704-7192
Country	:	US
Telephone Number	:	512-779-7101
Fax Number	:	512-494-0788

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	02/24/2010

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