Healthcare Provider Details

I. General information

NPI: 1376168682
Provider Name (Legal Business Name): EDGE OF TOWN PRODUCTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

746 DAYRIDGE DR
DRIPPING SPRINGS TX
78620-2128
US

IV. Provider business mailing address

746 DAYRIDGE DR
DRIPPING SPRINGS TX
78620-2128
US

V. Phone/Fax

Practice location:
  • Phone: 512-537-7104
  • Fax:
Mailing address:
  • Phone: 512-537-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN C POHL
Title or Position: LMFT
Credential: LMFT
Phone: 512-537-7104