MEDICARE: CENTRO DE MI SALUD

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

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	:	1952555153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO DE MI SALUD

Provider Business Mailing Address
First Line	:	13043 GEORGE FOSTER RD
Second Line	:
City	:	PONDER
State	:	TX
Zip	:	76259-4009
Country	:	US
Telephone Number	:	214-941-0798
Fax Number	:	214-941-0408

Provider Business Practice Location Address
First Line	:	628 CENTRE ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-6328
Country	:	US
Telephone Number	:	214-941-0798
Fax Number	:	214-941-0408

Authorized Official
Title or Position	:	QMHP
Name	:	MR. MICHEAL CHRISTOPHER RAVEN
Credential	:	BSW
Telephone Number	:	214-941-0798

Provider Enumeration Date	:	11/14/2008
Last Update Date	:	11/14/2008

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Directions to “CENTRO DE MI SALUD ” Practice Location

Language	Start Address	Practice Location

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