MEDICARE: HILTON J LASALLE III ED.D.

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1619850062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HILTON J LASALLE III ED.D.

Provider Business Mailing Address
First Line	:	3830 WENTWORTH ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-6510
Country	:	US
Telephone Number	:	225-773-4347
Fax Number	:

Provider Business Practice Location Address
First Line	:	3830 WENTWORTH ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-6510
Country	:	US
Telephone Number	:	225-773-4347
Fax Number	:

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

Provider Enumeration Date	:	07/30/2025
Last Update Date	:	07/30/2025

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