=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710196233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSPERITY BEHAVIORAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 05/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2646 S LOOP W STE 104
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-2677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-775-5203
-----------------------------------------------------
Fax | 346-223-1898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2646 S LOOP W STE 104
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-2677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-775-5203
-----------------------------------------------------
Fax | 346-223-1898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | VANAVIA NAOMI RICHARDSON
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 832-775-5203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 14325
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------