Healthcare Provider Details

I. General information

NPI: 1306261987
Provider Name (Legal Business Name): SHOOK WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14703 EMERALD CYPRESS LN
CYPRESS TX
77429-4612
US

IV. Provider business mailing address

14703 EMERALD CYPRESS LN
CYPRESS TX
77429-4612
US

V. Phone/Fax

Practice location:
  • Phone: 281-631-5296
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateTX

VIII. Authorized Official

Name: RACHELLE BOUDREAUX
Title or Position: OWNER
Credential:
Phone: 832-302-7800