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NPI Code Detail

MEDICARE: UPSIDE WELLNESS, PLLC

MEDICARE: UPSIDE WELLNESS, 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
1101YP2500XProfessional Counselor72859TX

General Provider Information

NPI Number : 1336534882
Entity Type Code : Organization
Provider Name (Legal Business Name) : UPSIDE WELLNESS, PLLC
Provider Business Mailing Address
First Line : 3705 MEDICAL PKWY STE 520
Second Line :
City : AUSTIN
State : TX
Zip : 78705-1029
Country : US
Telephone Number : 512-900-5805
Fax Number : 512-287-4314
Provider Business Practice Location Address
First Line : 3705 MEDICAL PKWY STE 520
Second Line :
City : AUSTIN
State : TX
Zip : 78705-1029
Country : US
Telephone Number : 512-900-5805
Fax Number : 512-287-4314
Authorized Official
Title or Position : OWNER
Name : THOMAS LANE INGRAM
Credential : LPC
Telephone Number : 512-900-5805
Provider Enumeration Date : 04/01/2015
Last Update Date : 04/01/2015

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