=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710421771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COACHES: ACCESS OVERFLOW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2016
-----------------------------------------------------
Last Update Date | 12/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2002 HOLCOMBE BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-823-0888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16210 SIERRA GRANDE DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77083-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-823-0888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CONSULTATNT
-----------------------------------------------------
Name | MR. MAURICE STRINGFELLOW
-----------------------------------------------------
Credential | ATHLETIC TRAINER
-----------------------------------------------------
Telephone | 281-901-7395
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------