=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366440737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILL COUNTRY CHRISTIAN COUNSELING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 02/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1127 MAIN ST STE 100
-----------------------------------------------------
City | KERRVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78028-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-257-3009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1127 MAIN ST STE 100
-----------------------------------------------------
City | KERRVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78028-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-257-3009
-----------------------------------------------------
Fax | 830-257-3061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | BRENDA FUDGE
-----------------------------------------------------
Credential | DIRECTOR
-----------------------------------------------------
Telephone | 830-257-3009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 18662
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------