=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831824754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTURION PLACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2022
-----------------------------------------------------
Last Update Date | 04/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 WILCREST DR STE 300
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77042-2754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-364-2828
-----------------------------------------------------
Fax | 713-358-9692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 105
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77001-0105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-939-1966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FREDRIC NAVARRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-939-1966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------