=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124339429
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY FAMILY ENRICHMENT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2010
-----------------------------------------------------
Last Update Date | 07/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22531 CHERRY LN
-----------------------------------------------------
City | FRANKSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75763-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-520-6404
-----------------------------------------------------
Fax | 903-876-4780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22531 CHERRY LN
-----------------------------------------------------
City | FRANKSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75763-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-520-6404
-----------------------------------------------------
Fax | 903-876-4780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. LARRY WAYNE WILBURN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 903-520-6404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 63697
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------