MEDICARE: MONA MENTORS COMMUNITY AGENCY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12165	OTHER	TX	THHS

General Provider Information

NPI Number	:	1144597956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONA MENTORS COMMUNITY AGENCY, INC.

Provider Business Mailing Address
First Line	:	1339 MACCLESBY LN
Second Line	:
City	:	CHANNELVIEW
State	:	TX
Zip	:	77530-4822
Country	:	US
Telephone Number	:	713-266-2080
Fax Number	:	800-434-4305

Provider Business Practice Location Address
First Line	:	6420 RICHMOND AVE
Second Line	:	SUITE 602
City	:	HOUSTON
State	:	TX
Zip	:	77057-5929
Country	:	US
Telephone Number	:	713-266-2080
Fax Number	:	800-434-4305

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. MONA ELLIS
Credential	:	P/CHW
Telephone Number	:	713-266-2090

Provider Enumeration Date	:	11/22/2011
Last Update Date	:	11/22/2011

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