Provider Demographics
NPI:1740928027
Name:MYSTIC MAZE THERAPY AND CONSULTATION, PLLC
Entity type:Organization
Organization Name:MYSTIC MAZE THERAPY AND CONSULTATION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LPC
Authorized Official - Phone:469-542-0463
Mailing Address - Street 1:722 OAKBLUFF DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1429
Mailing Address - Country:US
Mailing Address - Phone:469-542-0463
Mailing Address - Fax:
Practice Address - Street 1:1411 TAPERWICKE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-4609
Practice Address - Country:US
Practice Address - Phone:469-542-0463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-25
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty