=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285484139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT WAYNE GAERTNER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2024
-----------------------------------------------------
Last Update Date | 08/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19500 ST HWY 249 STE 120
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-824-8775
-----------------------------------------------------
Fax | 281-648-2200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 880 ELM DR
-----------------------------------------------------
City | BRENHAM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77833-6548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-451-1317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 88131
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 88131
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------