Healthcare Provider Details

I. General information

NPI: 1427405307
Provider Name (Legal Business Name): SELF EMPLOYEED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 IRIS ARBOR CT
CONROE TX
77301-1172
US

IV. Provider business mailing address

2 IRIS ARBOR CT
CONROE TX
77301-1172
US

V. Phone/Fax

Practice location:
  • Phone: 903-220-3485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number68520
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number201806
License Number StateTX

VIII. Authorized Official

Name: MRS. KAREN MICHELLE WEEKS
Title or Position: THERAPIST
Credential: MA, LMFT, LPC
Phone: 903-220-3485