Provider Demographics
NPI:1902565872
Name:VIVID LIVING THERAPY, PLLC
Entity Type:Organization
Organization Name:VIVID LIVING THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LADAWNYA
Authorized Official - Middle Name:HOOKS
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:512-781-1172
Mailing Address - Street 1:12600 HILL COUNTRY BLVD STE R-275
Mailing Address - Street 2:
Mailing Address - City:BEE CAVE
Mailing Address - State:TX
Mailing Address - Zip Code:78738-6768
Mailing Address - Country:US
Mailing Address - Phone:512-781-1172
Mailing Address - Fax:
Practice Address - Street 1:12600 HILL COUNTRY BLVD STE R-275
Practice Address - Street 2:
Practice Address - City:BEE CAVE
Practice Address - State:TX
Practice Address - Zip Code:78738-6768
Practice Address - Country:US
Practice Address - Phone:512-781-1172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health