=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962980623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNBEAM PSYCHOTHERAPY AND WELLNESS CONSULTANTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2018
-----------------------------------------------------
Last Update Date | 08/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2190 NORTH LOOP W STE 402
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77018-8129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-444-2756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1810 SEA QUEEN CT
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77008-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-444-2756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND CLINICAL DIRECTOR
-----------------------------------------------------
Name | JULIE GRINSFELDER WILKES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 713-444-2756
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 53434
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------