Healthcare Provider Details

I. General information

NPI: 1912699620
Provider Name (Legal Business Name): BUENA VISTA COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3007 DAWN DR STE 102
GEORGETOWN TX
78628-2864
US

IV. Provider business mailing address

210 TALLWOOD DR
GEORGETOWN TX
78628-8318
US

V. Phone/Fax

Practice location:
  • Phone: 512-876-3158
  • Fax:
Mailing address:
  • Phone: 512-876-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: VANESSA AGUIRRE
Title or Position: CO-OWNER
Credential: LPC-A
Phone: 512-876-3158