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General NPI Number Information
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NPI Number | 1417322157
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Entity Type | Organization
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Legal Business Name | PREMIERE COUNSELING AND RECOVERY SERVICES
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Dates
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Enumeration Date | 12/07/2015
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Last Update Date | 12/07/2015
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Provider Practice Location Address
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Address Line | 1341 W MOCKINGBIRD LN SUITE 600, WEST TOWER
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City | DALLAS
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State | TX
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Zip | 75247-6913
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Country | US
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Telephone | 214-274-6455
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 190841
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City | DALLAS
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State | TX
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Zip | 75219-0841
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Country | US
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Telephone | 214-274-6455
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. LAMONT CORNELIUS MARTIN
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Credential | LCDC
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Telephone | 214-274-6455
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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 | 12476
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License Number State | TX
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