Provider Demographics
NPI:1003513649
Name:PASSIONATE LIFE THERAPEUTIC ALLIANCE, PLLC
Entity Type:Organization
Organization Name:PASSIONATE LIFE THERAPEUTIC ALLIANCE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:832-224-5092
Mailing Address - Street 1:7676 HILLMONT ST STE 344-04
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6400
Mailing Address - Country:US
Mailing Address - Phone:832-224-5092
Mailing Address - Fax:
Practice Address - Street 1:7676 HILLMONT ST STE 344-04
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-6400
Practice Address - Country:US
Practice Address - Phone:832-224-5092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX79539OtherLPC LICENSE