MEDICARE: CLEAR LAKE COUNSELING SERVICESPCINC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	752A	TX

General Provider Information

NPI Number	:	1225046634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR LAKE COUNSELING SERVICESPCINC

Provider Business Mailing Address
First Line	:	17629 EL CAMINO REAL
Second Line	:	190
City	:	HOUSTON
State	:	TX
Zip	:	77058-2901
Country	:	US
Telephone Number	:	281-280-0393
Fax Number	:	281-280-0123

Provider Business Practice Location Address
First Line	:	17629 EL CAMINO REAL
Second Line	:	190
City	:	HOUSTON
State	:	TX
Zip	:	77058-2901
Country	:	US
Telephone Number	:	281-280-0393
Fax Number	:	281-280-0123

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS CYNTHIA LADDEL WHEELER
Credential	:	L.C.D.C.
Telephone Number	:	281-289-0393

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	08/22/2020

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