=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245726504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORING PEACE COUNSELING CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2018
-----------------------------------------------------
Last Update Date | 07/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 508 PAT BOOKER RD # 6023
-----------------------------------------------------
City | UNIVERSAL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78148-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-870-4007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12
-----------------------------------------------------
City | SCHERTZ
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78108-0012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER / OWNER
-----------------------------------------------------
Name | STEPHANIE JOHNSON
-----------------------------------------------------
Credential | PC
-----------------------------------------------------
Telephone | 210-870-4007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 18656
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------