Provider Demographics
NPI:1043648637
Name:HIVELY, MYSTI
Entity Type:Individual
Prefix:
First Name:MYSTI
Middle Name:
Last Name:HIVELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 CEDAR WOOD TRL
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-4542
Mailing Address - Country:US
Mailing Address - Phone:972-658-9372
Mailing Address - Fax:
Practice Address - Street 1:1801 CEDAR WOOD TRL
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:TX
Practice Address - Zip Code:75409-4542
Practice Address - Country:US
Practice Address - Phone:972-658-9372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68819101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional