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General NPI Number Information
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NPI Number | 1992215123
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Entity Type | Organization
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Legal Business Name | BODHI TRAIL WELLNESS, PLLC
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Dates
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Enumeration Date | 10/02/2017
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Last Update Date | 10/02/2017
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Provider Practice Location Address
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Address Line | 19240 REDLAND RD STE 235
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City | SAN ANTONIO
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State | TX
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Zip | 78259-3340
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Country | US
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Telephone | 210-417-3015
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Fax |
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Provider Business Mailing Address
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Address Line | 19240 REDLAND RD STE 235
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City | SAN ANTONIO
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State | TX
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Zip | 78259-3340
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Country | US
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Telephone | 210-417-3015
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. RACHEL SARAH LUNA
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Credential | LCSW
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Telephone | 210-417-3015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 56573
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License Number State | TX
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