Healthcare Provider Details

I. General information

NPI: 1730934464
Provider Name (Legal Business Name): YULIA YEZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3513 N FRAZIER ST
CONROE TX
77303-1430
US

IV. Provider business mailing address

3513 N FRAZIER ST
CONROE TX
77303-1430
US

V. Phone/Fax

Practice location:
  • Phone: 936-648-5379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number94319
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: