Healthcare Provider Details

I. General information

NPI: 1043404841
Provider Name (Legal Business Name): JOHN G. DIMLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 GARDENDALE ST SUITE 203
SAN ANTONIO TX
78229-3132
US

IV. Provider business mailing address

4204 GARDENDALE ST SUITE 203
SAN ANTONIO TX
78229-3132
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-8452
  • Fax: 210-614-8561
Mailing address:
  • Phone: 210-614-8452
  • Fax: 210-614-8561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21650
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14338
License Number StateTX

VIII. Authorized Official

Name: JOHN G. DIMLER
Title or Position: COUNSELOR
Credential: LPC, LCSW
Phone: 210-614-8452