Healthcare Provider Details

I. General information

NPI: 1992921019
Provider Name (Legal Business Name): STBM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12050 VANCE JACKSON BLDG. 2, STE. 201
SAN ANTONIO TX
78230-1183
US

IV. Provider business mailing address

12050 VANCE JACKSON BLDG. 2, STE. 201
SAN ANTONIO TX
78230-1183
US

V. Phone/Fax

Practice location:
  • Phone: 210-699-8881
  • Fax: 210-699-0503
Mailing address:
  • Phone: 210-699-8881
  • Fax: 210-699-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1884
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number22545
License Number StateTX

VIII. Authorized Official

Name: MRS. DIANE PENA
Title or Position: OFFICE MANAGER
Credential:
Phone: 210-699-8881