=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548613342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMANI COUNSELING SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2016
-----------------------------------------------------
Last Update Date | 05/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10333 HARWIN DR STE 490
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77036-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-501-0091
-----------------------------------------------------
Fax | 832-553-7811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10333 HARWIN DR STE 490
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77036-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-501-0091
-----------------------------------------------------
Fax | 832-553-7811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRYSTAL HUMPHREY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 281-501-0091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 66339
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------