MEDICARE: EAST TEXAS LEARNING LAB

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	252Y00000X	Early Intervention Provider Agency
2	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)
3	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1194591768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TEXAS LEARNING LAB

Provider Business Mailing Address
First Line	:	1073 COUNTY ROAD 212 E
Second Line	:
City	:	HENDERSON
State	:	TX
Zip	:	75652-4026
Country	:	US
Telephone Number	:	903-918-3492
Fax Number	:

Provider Business Practice Location Address
First Line	:	1504 W MAIN ST
Second Line	:
City	:	HENDERSON
State	:	TX
Zip	:	75652-2836
Country	:	US
Telephone Number	:	903-918-3492
Fax Number	:

Authorized Official
Title or Position	:	CEO/DIRECTOR
Name	:	KRISTAL CLAY
Credential	:	CEO
Telephone Number	:	903-918-3492

Provider Enumeration Date	:	11/27/2023
Last Update Date	:	04/30/2025

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Directions to “EAST TEXAS LEARNING LAB ” Practice Location

Language	Start Address	Practice Location

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