Provider Demographics
NPI:1396209052
Name:LAKE TRAVIS COUNSELING CONNECTION PLLC
Entity Type:Organization
Organization Name:LAKE TRAVIS COUNSELING CONNECTION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOPE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:512-263-4200
Mailing Address - Street 1:311 RANCH ROAD 620 S STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4747
Mailing Address - Country:US
Mailing Address - Phone:512-263-4200
Mailing Address - Fax:512-233-2867
Practice Address - Street 1:311 RANCH ROAD 620 S STE 105
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4747
Practice Address - Country:US
Practice Address - Phone:512-263-4200
Practice Address - Fax:512-233-2867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)