=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013332717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE MATIAS SANTOS III L.P.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2014
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 E BROADWAY ST
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-764-6333
-----------------------------------------------------
Fax | 972-441-2385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 E BROADWAY ST
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-764-6333
-----------------------------------------------------
Fax | 972-441-2383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 69085
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------