Basic Information
Provider Information | |||||||||
NPI: | 1336254184 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STAR COUNCIL ON SUBSTANCE ABUSE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 239 S VIRGINIA ST | ||||||||
Address2: |   | ||||||||
City: | STEPHENVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 764014344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2549655515 | ||||||||
FaxNumber: | 2549657416 | ||||||||
Practice Location | |||||||||
Address1: | 239 S VIRGINIA ST | ||||||||
Address2: |   | ||||||||
City: | STEPHENVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 764014344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2549655515 | ||||||||
FaxNumber: | 2549657416 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOITNOTT | ||||||||
AuthorizedOfficialFirstName: | DANNY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2549655515 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 859-A | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.