Basic Information
| Provider Information | |||||||||
| NPI: | 1013143767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE CONE THERAPIES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2104 GREENBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760928355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174429022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2104 GREENBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760928355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174429022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | RECORDS | ||||||||
| AuthorizedOfficialFirstName: | BOBBYE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8174429022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-10-7860 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.