MEDICARE: FAITH WORKS HEALTH AND WELLNESS NETWORK

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	101YP2500X	Professional Counselor	230335	TX
2	163W00000X	Registered Nurse	230335	TX
3	171M00000X	Case Manager/Care Coordinator
4	343900000X	Non-emergency Medical Transport (VAN)
5	207Q00000X	Family Medicine Physician	K1282	TX

General Provider Information

NPI Number	:	1487881306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAITH WORKS HEALTH AND WELLNESS NETWORK

Provider Business Mailing Address
First Line	:	4112 AUSTIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-4813
Country	:	US
Telephone Number	:	713-884-0884
Fax Number	:	713-583-5877

Provider Business Practice Location Address
First Line	:	4112 AUSTIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-4813
Country	:	US
Telephone Number	:	713-884-0884
Fax Number	:	713-583-5877

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DR. RICHARD EARL WILSON II
Credential	:	ED. D
Telephone Number	:	713-884-0884

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	06/18/2009

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Directions to “FAITH WORKS HEALTH AND WELLNESS NETWORK ” Practice Location

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