Provider Demographics
NPI:1356914501
Name:FINE, MANDY (LPC, LCDC)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:FINE
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 AVON LN STE 190B
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-1549
Mailing Address - Country:US
Mailing Address - Phone:972-259-0109
Mailing Address - Fax:
Practice Address - Street 1:4645 AVON LN STE 190B
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-1549
Practice Address - Country:US
Practice Address - Phone:972-259-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15474101YA0400X
TX85855101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty