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General NPI Number Information
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NPI Number | 1740458421
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Entity Type | Organization
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Legal Business Name | IDENTITY DEVELOPMENT COUNSELING AND FAMILY RESOURCE CENTER
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Dates
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Enumeration Date | 02/14/2008
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 21714 HARDY OAK SUITE 104
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City | SAN ANTONIO
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State | TX
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Zip | 78258
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Country | US
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Telephone | 210-490-9062
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Fax | 210-490-8843
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Provider Business Mailing Address
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Address Line | 21714 HARDY OAK SUITE 104
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City | SAN ANTONIO
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State | TX
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Zip | 78258
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Country | US
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Telephone | 210-490-9062
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Fax | 210-490-8843
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Authorized Official
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Title or Position | DIRECTOR OWNER
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Name | DR. JOHN HENRY KOINER
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Credential | LPC LMFT NCC
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Telephone | 210-490-9062
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 000552
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 001123
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License Number State | TX
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