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General NPI Number Information
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NPI Number | 1750046074
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Entity Type | Organization
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Legal Business Name | KSA ADDICTION TREATMENT LLC
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Dates
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Enumeration Date | 11/02/2021
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 132 HILLSIDE LN
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City | DESOTO
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State | TX
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Zip | 75115-5910
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Country | US
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Telephone | 469-321-1346
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Fax |
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Provider Business Mailing Address
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Address Line | 132 HILLSIDE LN
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City | DESOTO
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State | TX
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Zip | 75115-5910
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Country | US
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Telephone | 469-321-1346
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Fax |
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Authorized Official
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Title or Position | LICENSED CHEMICAL DEPENDENCY
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Name | MYLAN WATSON-SHAW
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Credential | LCDC
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Telephone | 469-321-1346
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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