Provider Demographics
NPI:1528338928
Name:BEDROCK COUNSELING, PLLC
Entity type:Organization
Organization Name:BEDROCK COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:POLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCDCI
Authorized Official - Phone:214-680-5074
Mailing Address - Street 1:575 N VALLEY PKWY
Mailing Address - Street 2:230
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3667
Mailing Address - Country:US
Mailing Address - Phone:972-906-9112
Mailing Address - Fax:972-906-9125
Practice Address - Street 1:575 N VALLEY PKWY
Practice Address - Street 2:230
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3667
Practice Address - Country:US
Practice Address - Phone:972-906-9112
Practice Address - Fax:972-906-9125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation