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General NPI Number Information
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NPI Number | 1629473772
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Entity Type | Organization
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Legal Business Name | INITIATIVE FOR CHANGE & DEVELOPMENT COUNSELING SERVICES, PLLC
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Dates
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Enumeration Date | 10/31/2014
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Last Update Date | 10/31/2014
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Provider Practice Location Address
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Address Line | 1300 MCGOWEN ST
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City | HOUSTON
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State | TX
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Zip | 77004-1141
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Country | US
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Telephone | 713-714-8538
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Fax | 713-714-8841
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Provider Business Mailing Address
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Address Line | 1300 MCGOWEN ST
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City | HOUSTON
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State | TX
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Zip | 77004-1141
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Country | US
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Telephone | 713-714-8538
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Fax | 713-714-8841
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. ALAN ROY BLACKSHEAR
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Credential | LCDC, CART, COPSD
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Telephone | 713-714-8539
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 11387
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License Number State | TX
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