=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457531063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING EXPRESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2007
-----------------------------------------------------
Last Update Date | 06/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1125 N ROBISON RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-832-2890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1125 N ROBISON RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-832-2890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MR. PHILLIP RAY SIMMONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-832-2890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 50796
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------