Provider Demographics
NPI:1992207054
Name:PEDIATRIC COUNSELING OF MANSFIELD, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC COUNSELING OF MANSFIELD, PLLC
Other - Org Name:PEDIATRIC AND FAMILY COUNSELING OF TEXARKANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-422-7070
Mailing Address - Street 1:1848 LONE STAR RD STE 125
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5791
Mailing Address - Country:US
Mailing Address - Phone:682-422-7070
Mailing Address - Fax:682-323-0944
Practice Address - Street 1:1848 LONE STAR RD STE 125
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5791
Practice Address - Country:US
Practice Address - Phone:682-422-7070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-05
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73578101YP2500X
261QM0855X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345128803Medicaid