=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336691229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLABORATIVE COUNSELING OF KINGWOOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2016
-----------------------------------------------------
Last Update Date | 10/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2316 TIMBER SHADOWS DR STE 202
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-726-4230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 977
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365-0977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TARA LISA CAMERON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 281-726-4230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 57034
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------