Provider Demographics
NPI:1245755081
Name:WATERSHED GROUP OF DALLAS, PLLC
Entity Type:Organization
Organization Name:WATERSHED GROUP OF DALLAS, PLLC
Other - Org Name:LIFEOLOGIE PLANO RICHARDSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LY
Authorized Official - Middle Name:HAI
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPS-SUPERVISOR
Authorized Official - Phone:214-556-0996
Mailing Address - Street 1:3600 SHIRE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2238
Mailing Address - Country:US
Mailing Address - Phone:214-556-0996
Mailing Address - Fax:
Practice Address - Street 1:3600 SHIRE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2238
Practice Address - Country:US
Practice Address - Phone:214-556-0996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63770101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty