MEDICARE: ESSANCE SAMPLE

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1255268330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ESSANCE SAMPLE

Provider Business Mailing Address
First Line	:	6222 W IH 10 STE 104
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-2013
Country	:	US
Telephone Number	:	210-447-0039
Fax Number	:

Provider Business Practice Location Address
First Line	:	1824 SAWDUST RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77380-3667
Country	:	US
Telephone Number	:	210-447-0039
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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Directions to “ ESSANCE SAMPLE ” Practice Location

Language	Start Address	Practice Location

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