1194068585 NPI number — IMAGINE COUNSELING LLC

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 1194068585 NPI number — IMAGINE COUNSELING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMAGINE COUNSELING LLC
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:
1194068585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 782503
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78278-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-479-9300
Provider Business Mailing Address Fax Number:
210-479-9300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4081 DEZAVALA RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78249-2082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-479-9300
Provider Business Practice Location Address Fax Number:
210-479-9300
Provider Enumeration Date:
04/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MEJIA-DESATNIK
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
DEL CARMEN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
210-479-9300

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , 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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