=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316703440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEOFFREY L BALL LCDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2024
-----------------------------------------------------
Last Update Date | 02/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2627 CAROLINE ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-392-7593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2030 FOXTAIL CREEK CT
-----------------------------------------------------
City | CROSBY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77532-1983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-618-0608
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 14588
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------