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General NPI Number Information
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NPI Number | 1376872986
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Entity Type | Organization
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Legal Business Name | KALOS COUNSELING AND DIAGNOSTICS, PLLC
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Dates
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Enumeration Date | 12/09/2009
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Last Update Date | 12/09/2009
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Provider Practice Location Address
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Address Line | 1091 N MAIN ST
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City | VIDOR
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State | TX
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Zip | 77662-4339
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Country | US
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Telephone | 409-769-8910
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Fax | 409-769-8914
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Provider Business Mailing Address
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Address Line | PO BOX 624
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City | VIDOR
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State | TX
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Zip | 77670-0624
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Country | US
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Telephone | 409-769-8910
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Fax | 409-769-8914
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Authorized Official
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Title or Position | MANAGER
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Name | MR. BENJAMIN SCOTT ODOM
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Credential | M.ED., LPC
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Telephone | 409-769-8910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 62334
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 63792
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License Number State | TX
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