1659672251 NPI number — LEGACY VALLEY COUNSELING

Table of content: (NPI 1659672251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659672251 NPI number — LEGACY VALLEY COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY VALLEY COUNSELING
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:
1659672251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1165 COUNTY ROAD 2699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMETA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76853-3913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-752-3106
Provider Business Mailing Address Fax Number:
512-752-4428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19206 HUEBNER RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78258-3146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-497-2880
Provider Business Practice Location Address Fax Number:
210-497-7664
Provider Enumeration Date:
11/12/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
512-752-3106

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  7430 , 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)