Healthcare Provider Details

I. General information

NPI: 1104057066
Provider Name (Legal Business Name): KEVIN JOSTAN PRINCE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W. DEAN KEATON DRIVE HEALTH PROMOTION RESOURCE CENTER, SSB 1.106
AUSTIN TX
78712
US

IV. Provider business mailing address

PO BOX 7339 HEALTH PROMOTION RESOURCE CENTER
AUSTIN TX
78713-7339
US

V. Phone/Fax

Practice location:
  • Phone: 512-475-8252
  • Fax: 512-475-8459
Mailing address:
  • Phone: 512-475-8252
  • Fax: 512-475-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: