1568805364 NPI number — INTEGRATED BEHAVIORAL HEALTH & WELLNESS CONSULTANTS, PLLC

Table of content: (NPI 1568805364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568805364 NPI number — INTEGRATED BEHAVIORAL HEALTH & WELLNESS CONSULTANTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED BEHAVIORAL HEALTH & WELLNESS CONSULTANTS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1568805364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 HERMANN MUSEUM CIRCLE DR APT 5108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77004-7970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-232-0034
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2646 S LOOP W
Provider Second Line Business Practice Location Address:
180 D
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77054-2665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-997-7001
Provider Business Practice Location Address Fax Number:
888-870-6542
Provider Enumeration Date:
04/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOUDREAUX
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
713-232-0034

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  35073 , 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)

  • Identifier: 3259929 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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