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NPI Code Detail

MEDICARE: SOUTHEAST TEXAS CHILD GUIDANCE CENTER, PLLC

MEDICARE: SOUTHEAST TEXAS CHILD GUIDANCE CENTER, PLLC
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1861761017
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHEAST TEXAS CHILD GUIDANCE CENTER, PLLC
Provider Business Mailing Address
First Line : PO BOX 21313
Second Line :
City : BEAUMONT
State : TX
Zip : 77720-1313
Country : US
Telephone Number : 409-813-1765
Fax Number : 409-813-1875
Provider Business Practice Location Address
First Line : 3250 MEDICAL CENTER DR
Second Line :
City : BEAUMONT
State : TX
Zip : 77701-4627
Country : US
Telephone Number : 409-813-1765
Fax Number : 409-813-1875
Authorized Official
Title or Position : OWNER/DIRECTOR
Name : DR. RAVIKUMAR KANNEGANTI
Credential : M.D.
Telephone Number : 409-813-1765
Provider Enumeration Date : 12/16/2011
Last Update Date : 05/05/2015

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