MEDICARE: NORTH STAR WELLNESS, LLC

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	101YP2500X	Professional Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1366077935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH STAR WELLNESS, LLC

Provider Business Mailing Address
First Line	:	448 STARBOARD DR
Second Line	:
City	:	CROWLEY
State	:	TX
Zip	:	76036-3465
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 E RENFRO ST STE 201
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-3940
Country	:	US
Telephone Number	:	817-952-9215
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ANA DEL CARMEN BOISE
Credential	:	LPC
Telephone Number	:	703-989-9512

Provider Enumeration Date	:	03/04/2020
Last Update Date	:	03/04/2020

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