=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730771882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAND NEW YOU COUNSELING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2021
-----------------------------------------------------
Last Update Date | 02/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5452 HIGHWAY 105 W STE 103
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-520-9124
-----------------------------------------------------
Fax | 936-666-2291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5452 HIGHWAY 105 W STE 103
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-520-9124
-----------------------------------------------------
Fax | 936-666-2291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CYNTHIA HEAD
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 936-202-0596
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------