MEDICARE: CODY SYLVESTER GRENWELGE 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	14955	TX

General Provider Information

NPI Number	:	1598395345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY SYLVESTER GRENWELGE LCDC

Provider Business Mailing Address
First Line	:	1127 MAIN ST STE 100
Second Line	:
City	:	KERRVILLE
State	:	TX
Zip	:	78028-3581
Country	:	US
Telephone Number	:	830-257-3009
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 MAIN ST STE 100
Second Line	:
City	:	KERRVILLE
State	:	TX
Zip	:	78028-3581
Country	:	US
Telephone Number	:	830-257-3009
Fax Number	:

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

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	01/21/2020

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