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General NPI Number Information
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NPI Number | 1700125275
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Entity Type | Organization
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Legal Business Name | EAST TEXAS RECOVERY
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Dates
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Enumeration Date | 02/04/2013
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Last Update Date | 02/08/2013
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Provider Practice Location Address
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Address Line | 700 STATE HWY 31 SUITE 100
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City | CHANDLER
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State | TX
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Zip | 75758
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Country | US
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Telephone | 903-477-9178
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Fax |
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Provider Business Mailing Address
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Address Line | 521 NECHES DR
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City | CHANDLER
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State | TX
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Zip | 75758-9655
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Country | US
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Telephone | 903-477-9178
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MRS. STEPHANIE MARIE TEEL
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Credential | LCDC
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Telephone | 903-477-9178
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 3608
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License Number State | TX
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