MEDICARE: DESTANY SCHADDER LPC-A

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	89079	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	89079	OTHER	TX	ASSOCIATE

General Provider Information

NPI Number	:	1396471181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTANY SCHADDER LPC-A

Provider Business Mailing Address
First Line	:	1825 FORTVIEW RD STE 101
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-7654
Country	:	US
Telephone Number	:	512-937-3991
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 FORTVIEW RD STE 101
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-7654
Country	:	US
Telephone Number	:	512-937-3991
Fax Number	:

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

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	07/25/2022

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