MEDICARE: EMBODIED ART THERAPY AND COUNSELING 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	221700000X	Art Therapist
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1851038863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMBODIED ART THERAPY AND COUNSELING PLLC

Provider Business Mailing Address
First Line	:	8400 N MOPAC EXPY STE 301
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-8323
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8400 N MOPAC EXPY STE 301
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-8323
Country	:	US
Telephone Number	:	512-503-5030
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ART THERAPIST AND COUNSELOR
Name	:	MALLORY KATHLEEN KEEKS
Credential	:	LPC, ATR
Telephone Number	:	512-503-5030

Provider Enumeration Date	:	05/19/2022
Last Update Date	:	09/21/2022

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