Basic Information
Provider Information | |||||||||
NPI: | 1073556957 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STOWERS WRIGHT | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CARLTON | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | ELLEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5524 BEE CAVES RD STE K4 | ||||||||
Address2: |   | ||||||||
City: | WEST LAKE HILLS | ||||||||
State: | TX | ||||||||
PostalCode: | 787465247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5126493050 | ||||||||
FaxNumber: | 5127176337 | ||||||||
Practice Location | |||||||||
Address1: | 12012 WICKCHESTER LN | ||||||||
Address2: | SUITE 550 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770791229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8324482800 | ||||||||
FaxNumber: | 8324482801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 01/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 32266 | TX | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 32266 | TX | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 162335701 | 05 | TX |   | MEDICAID | 162335702 | 05 | TX |   | MEDICAID | 86855A | 01 | TX | BCBS | OTHER |