MEDICARE: AUSTIN 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
1	101YP1600X	Pastoral Counselor

General Provider Information

NPI Number	:	1346490562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	10010 ANDERSON MILL RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78750-2127
Country	:	US
Telephone Number	:	512-257-0050
Fax Number	:	512-257-0050

Provider Business Practice Location Address
First Line	:	10010 ANDERSON MILL RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78750-2127
Country	:	US
Telephone Number	:	512-257-0050
Fax Number	:	512-257-0050

Authorized Official
Title or Position	:	PRESIDENT AND OWNER
Name	:	LISA BLACKWOOD
Credential	:	LCDC, LPC
Telephone Number	:	512-257-0050

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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