=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255605465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY ADVOCACY CASE MANAGEMENT SVS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2012
-----------------------------------------------------
Last Update Date | 03/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3139 W HOLCOMBE BLVD # 272
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-633-3010
-----------------------------------------------------
Fax | 800-262-5172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3139 W HOLCOMBE BLVD # 272
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-633-3010
-----------------------------------------------------
Fax | 800-262-5172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL ADMINISTRATOR
-----------------------------------------------------
Name | JANA GASTON-COACHMAN
-----------------------------------------------------
Credential | LBSW
-----------------------------------------------------
Telephone | 832-633-3010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 29035
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------