Provider Demographics
NPI:1447821053
Name:THROUGH THE MIRROR THERAPY PLLC
Entity type:Organization
Organization Name:THROUGH THE MIRROR THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:512-650-5042
Mailing Address - Street 1:618 COMAL AVE BLDG B-1
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-7600
Mailing Address - Country:US
Mailing Address - Phone:512-650-5042
Mailing Address - Fax:
Practice Address - Street 1:618 COMAL AVE BLDG B-1
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-7600
Practice Address - Country:US
Practice Address - Phone:512-650-5042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX415111010Medicaid