Basic Information
| Provider Information | |||||||||
| NPI: | 1477646909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE HEALING PLACE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE HEALING PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 NW CENTRAL DR. SUITE 109 | ||||||||
| Address2: | SAME AS ABOVE | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138950062 | ||||||||
| FaxNumber: | 2818970413 | ||||||||
| Practice Location | |||||||||
| Address1: | 5450 NW CENTRAL DR. SUITE 109 | ||||||||
| Address2: | SAME AS ABOVE | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138950062 | ||||||||
| FaxNumber: | 2818970413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATTIS | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED PROFESSIONAL COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 7138950062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 18918 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | 17843 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.