MEDICARE: IMPACT HOMES

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

General Provider Information

NPI Number	:	1235818329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT HOMES

Provider Business Mailing Address
First Line	:	802 LAKE HAVEN CT
Second Line	:
City	:	HIGHLAND VLG
State	:	TX
Zip	:	75077-6478
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	802 LAKE HAVEN CT
Second Line	:
City	:	HIGHLAND VLG
State	:	TX
Zip	:	75077-6478
Country	:	US
Telephone Number	:	832-529-7370
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RUTH LAVINIA
Credential	:
Telephone Number	:	832-529-7370

Provider Enumeration Date	:	07/14/2023
Last Update Date	:	07/14/2023

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Directions to “IMPACT HOMES ” Practice Location

Language	Start Address	Practice Location

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