Healthcare Provider Details

I. General information

NPI: 1992119234
Provider Name (Legal Business Name): TRISTAN JAMES HATHORN-WILKINS MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2014
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 HIGHWAY 7E E
NACOGDOCHES TX
75961-8918
US

IV. Provider business mailing address

1329 HIGHWAY 7E E
NACOGDOCHES TX
75961-8918
US

V. Phone/Fax

Practice location:
  • Phone: 936-615-7927
  • Fax:
Mailing address:
  • Phone: 936-615-7927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number68511
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: