=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760742076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES C POURTEAU LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2012
-----------------------------------------------------
Last Update Date | 05/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3141 BRIARCREST DR STE 510
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-774-2863
-----------------------------------------------------
Fax | 979-774-2863
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2811 OAKSIDE DR
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-4766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-739-3384
-----------------------------------------------------
Fax | 979-774-2863
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 63948
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------