Healthcare Provider Details

I. General information

NPI: 1750046074
Provider Name (Legal Business Name): KSA ADDICTION TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 HILLSIDE LN
DESOTO TX
75115-5910
US

IV. Provider business mailing address

132 HILLSIDE LN
DESOTO TX
75115-5910
US

V. Phone/Fax

Practice location:
  • Phone: 469-321-1346
  • Fax:
Mailing address:
  • Phone: 469-321-1346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MYLAN WATSON-SHAW
Title or Position: LICENSED CHEMICAL DEPENDENCY
Credential: LCDC
Phone: 469-321-1346