Provider Demographics
NPI:1891396313
Name:ON EPIPHANY LANE, LLC
Entity Type:Organization
Organization Name:ON EPIPHANY LANE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:NEULENE
Authorized Official - Last Name:LINDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:214-560-0304
Mailing Address - Street 1:603 MUNGER AVE # 100-239
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202-1839
Mailing Address - Country:US
Mailing Address - Phone:214-560-0304
Mailing Address - Fax:
Practice Address - Street 1:603 MUNGER AVE STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202-1840
Practice Address - Country:US
Practice Address - Phone:214-560-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1215272737OtherNPI