1073820817 NPI number — AMANDA SOISSON NCC, LPC

Table of content: AMANDA SOISSON NCC, LPC (NPI 1073820817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073820817 NPI number — AMANDA SOISSON NCC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOISSON
Provider First Name:
AMANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NCC, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073820817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17480 DALLAS PKWY
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75287-7337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-402-8302
Provider Business Mailing Address Fax Number:
972-407-1305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 SOUTH FWY
Provider Second Line Business Practice Location Address:
SUITE 602
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76115-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-402-8302
Provider Business Practice Location Address Fax Number:
817-923-2063
Provider Enumeration Date:
08/31/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  19753 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)