=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639191547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG TERM CARE SERVICES, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 WICKES ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78210-1161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-223-6488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 WICKES ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78210-1161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-223-6488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JUNE W. MAXFELDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-223-6488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------