1245660497 NPI number — COLLABORATIVE HEALING THERAPY

Table of content: (NPI 1245660497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245660497 NPI number — COLLABORATIVE HEALING THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLLABORATIVE HEALING THERAPY
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:
6
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:
1245660497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16607 BLANCO RD
Provider Second Line Business Mailing Address:
SUITE 502
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-416-1621
Provider Business Mailing Address Fax Number:
210-547-7861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16607 BLANCO RD
Provider Second Line Business Practice Location Address:
SUITE 502
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78232-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-416-1621
Provider Business Practice Location Address Fax Number:
210-547-7861
Provider Enumeration Date:
11/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HAMMILL
Authorized Official First Name:
BRANDY
Authorized Official Middle Name:
GLASS
Authorized Official Title or Position:
LICENSED PROFESSIONAL COUNSELOR
Authorized Official Telephone Number:
210-416-1621

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  64781 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: 201299 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 212432302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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