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General NPI Number Information
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NPI Number | 1134962319
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Entity Type | Organization
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Legal Business Name | HTTPS://NPPES.CMS.HHS.GOV/IAWEB/LOGIN.DO
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Dates
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Enumeration Date | 06/17/2024
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 703 S CHURCH ST BLDG 2
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City | GEORGETOWN
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State | TX
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Zip | 78626-5749
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Country | US
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Telephone | 512-591-7305
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Fax |
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Provider Business Mailing Address
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Address Line | 703 S CHURCH ST BLDG 2
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City | GEORGETOWN
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State | TX
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Zip | 78626-5749
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Country | US
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Telephone | 254-258-3769
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Fax |
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Authorized Official
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Title or Position | CEO/FOUNDER
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Name | MS. SONJA SHARYN COUSAR
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Credential | LPC
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Telephone | 512-591-7305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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