=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790187813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY SERVICES OF NORTHEAST TEXAS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2014
-----------------------------------------------------
Last Update Date | 09/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 E HOUSTON ST BOX 427
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-756-5596
-----------------------------------------------------
Fax | 903-756-7294
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 E HOUSTON ST BOX 427
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-756-5596
-----------------------------------------------------
Fax | 903-756-7294
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. DAN LUCKY BOYD
-----------------------------------------------------
Credential | NCRT
-----------------------------------------------------
Telephone | 903-756-5596
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------