Healthcare Provider Details

I. General information

NPI: 1013143767
Provider Name (Legal Business Name): PINE CONE THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

IV. Provider business mailing address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-9022
  • Fax:
Mailing address:
  • Phone: 817-442-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-10-7860
License Number StateTX

VIII. Authorized Official

Name: BOBBYE R RECORDS
Title or Position: OWNER
Credential: BCBA
Phone: 817-442-9022