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General NPI Number Information
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NPI Number | 1780901702
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Entity Type | Organization
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Legal Business Name | IMAGINE THERAPIES, LLC
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Dates
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Enumeration Date | 04/29/2010
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Last Update Date | 04/29/2010
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Provider Practice Location Address
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Address Line | 14314 DUSKY THRUSH
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City | SAN ANTONIO
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State | TX
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Zip | 78233-5383
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Country | US
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Telephone | 210-995-6918
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Fax |
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Provider Business Mailing Address
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Address Line | 14314 DUSKY THRUSH
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City | SAN ANTONIO
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State | TX
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Zip | 78233-5383
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Country | US
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Telephone | 210-995-6918
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Fax |
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Authorized Official
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Title or Position | PARTNER, EXECUTIVE DIRECTOR
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Name | MRS. BROOKE DOEGEY CORTEZ
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Credential | MT-BC
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Telephone | 210-995-6918
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225800000X
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Taxonomy Name | Recreation Therapist
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License Number | 44621
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 225A00000X
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Taxonomy Name | Music Therapist
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License Number | 06122
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License Number State | TX
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