Healthcare Provider Details

I. General information

NPI: 1457823734
Provider Name (Legal Business Name): CLINTON R GHOLSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 SCARBOUROUGH
CANYON LAKE TX
78133-4529
US

IV. Provider business mailing address

5447 HAWK EYE DR
BULVERDE TX
78163-2255
US

V. Phone/Fax

Practice location:
  • Phone: 830-964-4390
  • Fax:
Mailing address:
  • Phone: 210-392-9520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number77796
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: