Healthcare Provider Details

I. General information

NPI: 1982059283
Provider Name (Legal Business Name): 11TH HOUR COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 SHERRY LN
SAGINAW TX
76179
US

IV. Provider business mailing address

949 SHERRY LN
SAGINAW TX
76179
US

V. Phone/Fax

Practice location:
  • Phone: 817-676-2422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number55382
License Number StateTX

VIII. Authorized Official

Name: MR. COREY PAVELKA
Title or Position: OWNER
Credential:
Phone: 817-676-2422