Basic Information
| Provider Information | |||||||||
| NPI: | 1275807216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STAR COUNCIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 W HEARD ST | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760333836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176455517 | ||||||||
| FaxNumber: | 8176455715 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 W HEARD ST | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760333836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176455517 | ||||||||
| FaxNumber: | 8176455715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2012 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | KRISTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 8175017098 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.S., LPC-INTERN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 68618 | TX | Y | Agencies | Community/Behavioral Health |
No ID Information.