Healthcare Provider Details

I. General information

NPI: 1235367384
Provider Name (Legal Business Name): NEW DESTINATIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 COUNTY ROAD 433
TENAHA TX
75974-6332
US

IV. Provider business mailing address

PO BOX 1515
CARTHAGE TX
75633-7515
US

V. Phone/Fax

Practice location:
  • Phone: 936-248-2322
  • Fax:
Mailing address:
  • Phone: 936-248-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20345
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number106894
License Number StateTX

VIII. Authorized Official

Name: MS. TERRIE MAE KING
Title or Position: PROGRAM COORDINATOR
Credential: LOT
Phone: 903-692-3463