MEDICARE: CROCKETT COUNSELING CENTER , LLC

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	101YM0800X	Mental Health Counselor	19494	TX

General Provider Information

NPI Number	:	1144631573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROCKETT COUNSELING CENTER , LLC

Provider Business Mailing Address
First Line	:	1025 E HOUSTON AVE
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-2240
Country	:	US
Telephone Number	:	936-546-7887
Fax Number	:	936-544-9749

Provider Business Practice Location Address
First Line	:	1320 E HOUSTON AVE
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1761
Country	:	US
Telephone Number	:	936-544-9484
Fax Number	:	936-544-9749

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KARISA CORLEY BURKE
Credential	:	LPC
Telephone Number	:	936-546-7887

Provider Enumeration Date	:	05/20/2014
Last Update Date	:	05/20/2014

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Directions to “CROCKETT COUNSELING CENTER , LLC ” Practice Location

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