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General NPI Number Information
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NPI Number | 1144631573
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Entity Type | Organization
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Legal Business Name | CROCKETT COUNSELING CENTER , LLC
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Dates
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Enumeration Date | 05/20/2014
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Last Update Date | 05/20/2014
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Provider Practice Location Address
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Address Line | 1320 E HOUSTON AVE
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City | CROCKETT
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State | TX
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Zip | 75835-1761
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Country | US
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Telephone | 936-544-9484
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Fax | 936-544-9749
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Provider Business Mailing Address
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Address Line | 1025 E HOUSTON AVE
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City | CROCKETT
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State | TX
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Zip | 75835-2240
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Country | US
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Telephone | 936-546-7887
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Fax | 936-544-9749
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Authorized Official
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Title or Position | PRESIDENT
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Name | KARISA CORLEY BURKE
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Credential | LPC
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Telephone | 936-546-7887
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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 | 19494
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License Number State | TX
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