MEDICARE: CORNERSTONE WELLNESS GROUP, 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	12361	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407266604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE WELLNESS GROUP, LLC

Provider Business Mailing Address
First Line	:	405 E. CROCKETT ST.
Second Line	:
City	:	CLEVELAND
State	:	TX
Zip	:	77327-9998
Country	:	US
Telephone Number	:	281-593-1888
Fax Number	:	281-593-1890

Provider Business Practice Location Address
First Line	:	405 E. CROCKETT ST.
Second Line	:
City	:	CLEVELAND
State	:	TX
Zip	:	77327-9998
Country	:	US
Telephone Number	:	281-593-1888
Fax Number	:	281-593-1890

Authorized Official
Title or Position	:	LICENSED PROFFESIONAL COUNSELOR
Name	:	LOIS MARIE LIDDLE
Credential	:	LPC-S
Telephone Number	:	281-593-1888

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	04/28/2014

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