Healthcare Provider Details

I. General information

NPI: 1124886486
Provider Name (Legal Business Name): SALEM THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

9800 PAGEWOOD LN APT 2605
HOUSTON TX
77042-5531
US

IV. Provider business mailing address

9800 PAGEWOOD LN APT 2605
HOUSTON TX
77042-5531
US

V. Phone/Fax

Practice location:
  • Phone: 832-308-0764
  • Fax:
Mailing address:
  • Phone: 832-308-0764
  • 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 Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. EVAN SMITH
Title or Position: CEO
Credential:
Phone: 832-308-0764