Healthcare Provider Details

I. General information

NPI: 1780901702
Provider Name (Legal Business Name): IMAGINE THERAPIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14314 DUSKY THRUSH
SAN ANTONIO TX
78233-5383
US

IV. Provider business mailing address

14314 DUSKY THRUSH
SAN ANTONIO TX
78233-5383
US

V. Phone/Fax

Practice location:
  • Phone: 210-995-6918
  • Fax:
Mailing address:
  • Phone: 210-995-6918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number44621
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number06122
License Number StateTX

VIII. Authorized Official

Name: MRS. BROOKE DOEGEY CORTEZ
Title or Position: PARTNER, EXECUTIVE DIRECTOR
Credential: MT-BC
Phone: 210-995-6918