Healthcare Provider Details

I. General information

NPI: 1184926263
Provider Name (Legal Business Name): PERSONAL TRANSFORMATION WELLNESS GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 MED COURT, STE. #106
SAN ANTONIO TX
78258-4203
US

IV. Provider business mailing address

P.O. BOX 591337
SAN ANTONIO TX
78259-0116
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-0675
  • Fax: 210-495-0884
Mailing address:
  • Phone: 210-495-0675
  • Fax: 210-495-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LOURDES AGUILAR-LANDIN
Title or Position: CLINICAL DIRECTOR
Credential: MS, LPC, LMFT
Phone: 210-495-0675