Healthcare Provider Details

I. General information

NPI: 1700487816
Provider Name (Legal Business Name): TOTAL RESTORATION BEHAVIORAL SCIENCE AND COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9823 BRILLIANT LAKE DR
HUMBLE TX
77396-1570
US

IV. Provider business mailing address

9659 N SAM HOUSTON PKWY E # 227
HUMBLE TX
77396-1529
US

V. Phone/Fax

Practice location:
  • Phone: 301-556-8665
  • Fax:
Mailing address:
  • Phone: 301-556-8665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. EARNEST LEE PUGH
Title or Position: CEO
Credential: MDIV, DMIN
Phone: 301-556-8665