1407000508 NPI number — CORRECTIONAL REHABILITATION SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407000508 NPI number — CORRECTIONAL REHABILITATION SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORRECTIONAL REHABILITATION SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407000508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1304 NUECES STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-708-0502
Provider Business Mailing Address Fax Number:
512-708-0557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4833 SPICEWOOD SPRINGS RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-8436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-708-0502
Provider Business Practice Location Address Fax Number:
512-708-0557
Provider Enumeration Date:
11/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FERRARA
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
LUKE
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
512-708-0502

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  22796 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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