Healthcare Provider Details

I. General information

NPI: 1871004507
Provider Name (Legal Business Name): BRENT PARKER TANKSLEY LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501C S WHEELER ST
JASPER TX
75951-5103
US

IV. Provider business mailing address

1204 JANE AVE
LUFKIN TX
75901-1450
US

V. Phone/Fax

Practice location:
  • Phone: 409-622-9252
  • Fax:
Mailing address:
  • Phone: 936-674-6559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13677
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: