MEDICARE: THE EXTENDED OLIVE BRANCH COUNSELING CENTER LLC

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	103TC1900X	Counseling Psychologist
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1619645975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE EXTENDED OLIVE BRANCH COUNSELING CENTER LLC

Provider Business Mailing Address
First Line	:	16320 HUEBNER RD STE 200
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78248-1690
Country	:	US
Telephone Number	:	830-443-0553
Fax Number	:

Provider Business Practice Location Address
First Line	:	16320 HUEBNER RD STE 200
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78248-1690
Country	:	US
Telephone Number	:	830-443-0553
Fax Number	:	830-215-0223

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOSHUA T GARCIA
Credential	:
Telephone Number	:	830-443-0553

Provider Enumeration Date	:	09/01/2021
Last Update Date	:	09/14/2021

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