Healthcare Provider Details

I. General information

NPI: 1326231150
Provider Name (Legal Business Name): CONCRETE ROSE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 LIVE OAK ST
HOUSTON TX
77003-4408
US

IV. Provider business mailing address

12806 GLORYWHITE CT
HOUSTON TX
77034-3685
US

V. Phone/Fax

Practice location:
  • Phone: 832-563-8623
  • Fax:
Mailing address:
  • Phone: 832-563-8623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number20180
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20180
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20180
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number20180
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20180
License Number StateTX

VIII. Authorized Official

Name: ERIC S WELLS
Title or Position: PSYCHO-THERAPIST
Credential: LPC, LSTOP
Phone: 832-563-8623