=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720385404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY NETWORK OF EAST TEXAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2011
-----------------------------------------------------
Last Update Date | 02/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2912 E MAIN ST
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-5468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-560-6397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2912 E MAIN ST
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-5468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-560-6397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. THRESA ANNETTE CALDWELL
-----------------------------------------------------
Credential | LBSW-IPR
-----------------------------------------------------
Telephone | 936-560-4365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 27886
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------