1205430774 NPI number — CHARLA RAEANN KILLIAN M.A., LPC

Table of content: CHARLA RAEANN KILLIAN M.A., LPC (NPI 1205430774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205430774 NPI number — CHARLA RAEANN KILLIAN M.A., LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLIAN
Provider First Name:
CHARLA
Provider Middle Name:
RAEANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., LPC
Provider Gender Code:
F

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:
1205430774
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
597 CIRCLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BULLARD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75757-5505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-521-3550
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16075 OLD JACKSONVILLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-521-3550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  79596 , 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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