=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619457330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAKE FLIGHT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2018
-----------------------------------------------------
Last Update Date | 08/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16821 BUCCANEER LN STE 119
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77058-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-630-4825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 58084
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-8084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROF COUNSELOR/OWNER
-----------------------------------------------------
Name | MRS. PATRICE M. HOUSTON
-----------------------------------------------------
Credential | MA, LPC-S, LCDC
-----------------------------------------------------
Telephone | 281-630-4825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------