MEDICARE: SUMMIT CLINICAL SERVICES PLLC

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	14885	TX

General Provider Information

NPI Number	:	1225219090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMIT CLINICAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	2708 E TANAGER TRL
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77632-0750
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2708 E TANAGER TRL
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77632-0750
Country	:	US
Telephone Number	:	409-729-0400
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	LARRY WILSON
Credential	:	LPC
Telephone Number	:	409-729-0400

Provider Enumeration Date	:	11/20/2007
Last Update Date	:	11/20/2007

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Directions to “SUMMIT CLINICAL SERVICES PLLC ” Practice Location

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