Healthcare Provider Details

I. General information

NPI: 1295850311
Provider Name (Legal Business Name): KS STANLEY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 NORFOLK ST STE 204
HOUSTON TX
77098-1013
US

IV. Provider business mailing address

2211 NORFOLK ST STE 204
HOUSTON TX
77098-1013
US

V. Phone/Fax

Practice location:
  • Phone: 346-232-5060
  • Fax:
Mailing address:
  • Phone: 346-232-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36976
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: