MEDICARE: MR. HISE CARROLL AUSTIN II

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1538306519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HISE CARROLL AUSTIN II

Provider Business Mailing Address
First Line	:	5734 TIDEWATER DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77085-3362
Country	:	US
Telephone Number	:	713-899-7076
Fax Number	:	713-283-5192

Provider Business Practice Location Address
First Line	:	5734 TIDEWATER DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77085-3362
Country	:	US
Telephone Number	:	713-899-7076
Fax Number	:	713-283-5192

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2009
Last Update Date	:	01/13/2009

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