Provider Demographics
NPI:1124313432
Name:BACCHUS, MINDY BLOCK (LPC)
Entity type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:BLOCK
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W 9TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-5543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 W 9TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5543
Practice Address - Country:US
Practice Address - Phone:512-864-5911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63473101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional