=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902650575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEURODEVELOPMENT CENTER OF GREATER HOUSTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2024
-----------------------------------------------------
Last Update Date | 04/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4203 MONTROSE BLVD STE 290
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77006-5470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-881-6877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1304 BLODGETT ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-5011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-881-6877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DEVELOPMENTAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. TARA COKER DEVINE
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 281-881-6877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------