Healthcare Provider Details

I. General information

NPI: 1720571326
Provider Name (Legal Business Name): SEXUAL LIFE IMPROVEMENT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MORROW ST
AUSTIN TX
78752-1337
US

IV. Provider business mailing address

701 MORROW ST
AUSTIN TX
78752-1337
US

V. Phone/Fax

Practice location:
  • Phone: 512-431-3721
  • Fax:
Mailing address:
  • Phone: 512-431-3721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number51195
License Number StateTX

VIII. Authorized Official

Name: DR. SHELLEY IMHOLTE
Title or Position: OWNER
Credential:
Phone: 512-431-3721