MEDICARE: MR. REAL DELAVERGNE LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	9214	TX

General Provider Information

NPI Number	:	1386854388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. REAL DELAVERGNE LCDC

Provider Business Mailing Address
First Line	:	3304 CEDARCREST DR
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77503-2122
Country	:	US
Telephone Number	:	281-212-2918
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 BAY AREA BLVD # A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-2505
Country	:	US
Telephone Number	:	281-212-2918
Fax Number	:

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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