MEDICARE: NOURISH PLAY THERAPY 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	71350	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487037685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOURISH PLAY THERAPY LLC

Provider Business Mailing Address
First Line	:	5510 ABRAMS RD STE 120
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-2099
Country	:	US
Telephone Number	:	214-208-7469
Fax Number	:	866-294-6406

Provider Business Practice Location Address
First Line	:	5510 ABRAMS RD STE 120
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-2099
Country	:	US
Telephone Number	:	214-208-7469
Fax Number	:	866-294-6406

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	MRS. ANTOINETTE MARIE MARTINEZ
Credential	:	LPC
Telephone Number	:	214-208-7469

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	05/31/2016

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Directions to “NOURISH PLAY THERAPY LLC ” Practice Location

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