MEDICARE: BLOSSOMING BUTTERFLY COUNSELING CENTER PLLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1265195135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOSSOMING BUTTERFLY COUNSELING CENTER PLLC

Provider Business Mailing Address
First Line	:	4242 E PIEDRAS DR STE 114
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-1430
Country	:	US
Telephone Number	:	210-334-1819
Fax Number	:	210-800-9916

Provider Business Practice Location Address
First Line	:	4242 E PIEDRAS DR STE 114
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-1430
Country	:	US
Telephone Number	:	210-334-1819
Fax Number	:	210-800-9916

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	TIFFANEY M GIBBONS
Credential	:	LPC
Telephone Number	:	210-334-1819

Provider Enumeration Date	:	10/18/2021
Last Update Date	:	10/18/2021

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