Healthcare Provider Details

I. General information

NPI: 1083941686
Provider Name (Legal Business Name): HILDEBRANDO MIRELES III LPC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 DEL RIO BLVD STE A
EAGLE PASS TX
78852-3453
US

IV. Provider business mailing address

11205 AMBERINA
SAN ANTONIO TX
78245-3858
US

V. Phone/Fax

Practice location:
  • Phone: 830-757-0117
  • Fax: 830-757-0119
Mailing address:
  • Phone: 830-757-0117
  • Fax: 830-757-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number65437
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number65437
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: