Healthcare Provider Details

I. General information

NPI: 1710251012
Provider Name (Legal Business Name): ST JOSEPH COUNSELING & REHABILITATION SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3334 S SW LOOP 323 SUITE 108
TYLER TX
75701-9237
US

IV. Provider business mailing address

3334 S SW LOOP 323 SUITE 108
TYLER TX
75701-9237
US

V. Phone/Fax

Practice location:
  • Phone: 903-581-7973
  • Fax: 903-581-6605
Mailing address:
  • Phone: 903-581-7973
  • Fax: 903-581-6605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: KEN A CHINWEZE
Title or Position: ADMINISTRATOR
Credential:
Phone: 903-581-7973