Healthcare Provider Details

I. General information

NPI: 1134727837
Provider Name (Legal Business Name): MR. PRESTON WALKER BOUWHUIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14058 MEMORIAL DR
HOUSTON TX
77079-6848
US

IV. Provider business mailing address

1307 WESTWICK FOREST LN
HOUSTON TX
77043-4571
US

V. Phone/Fax

Practice location:
  • Phone: 281-752-0403
  • Fax:
Mailing address:
  • Phone: 832-503-8218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-127734
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: