=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154470185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOBBY S. CONWAY M.S. LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3644 FARM ROAD 909
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75426-8011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-427-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3644 FARM ROAD 909
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75426-8011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-427-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 17220
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------