1225208226 NPI number — MS. PROVILLA HENDERSON SCRUGGS M.ED.

Table of content: MS. PROVILLA HENDERSON SCRUGGS M.ED. (NPI 1225208226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225208226 NPI number — MS. PROVILLA HENDERSON SCRUGGS M.ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCRUGGS
Provider First Name:
PROVILLA
Provider Middle Name:
HENDERSON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED.
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:
1225208226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13010 FLAXSEED WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77477-3408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-564-4348
Provider Business Mailing Address Fax Number:
281-564-4786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8303 SOUTHWEST FWY
Provider Second Line Business Practice Location Address:
640
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77074-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-816-8984
Provider Business Practice Location Address Fax Number:
832-816-8984
Provider Enumeration Date:
03/05/2008

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: 101YA0400X , with the licence number:  723 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 1929 , 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: 070928901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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