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General NPI Number Information
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NPI Number | 1386854388
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Entity Type | Individual
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Provider Name | REAL DELAVERGNE LCDC
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Gender | Male
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1300 BAY AREA BLVD # A
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City | HOUSTON
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State | TX
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Zip | 77058-2505
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Country | US
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Telephone | 281-212-2918
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Fax |
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Provider Business Mailing Address
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Address Line | 3304 CEDARCREST DR
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City | PASADENA
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State | TX
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Zip | 77503-2122
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Country | US
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Telephone | 281-212-2918
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 9214
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License Number State | TX
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