Healthcare Provider Details

I. General information

NPI: 1942929559
Provider Name (Legal Business Name): TERRI RAE YANOVIAK LCDCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 PARK GROVE DR
KATY TX
77450-5590
US

IV. Provider business mailing address

21819 MOORTOWN CIR
KATY TX
77450-5968
US

V. Phone/Fax

Practice location:
  • Phone: 800-685-9796
  • Fax: 281-676-4444
Mailing address:
  • Phone: 713-471-7265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number56340
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: