1306676465 NPI number — INDIVIDUAL AND COUPLES THERAPY OF TEXAS

Table of content: (NPI 1306676465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306676465 NPI number — INDIVIDUAL AND COUPLES THERAPY OF TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIVIDUAL AND COUPLES THERAPY OF TEXAS
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:
1306676465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2706 CARMEL WOODS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEABROOK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77586-1557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-578-0474
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 E WALKER ST STE 102C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAGUE CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77573-3803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-498-5662
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
DITTRICH
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
713-578-0474

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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