Basic Information
Provider Information | |||||||||
NPI: | 1366591497 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STRANGE | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1222 N. MAIN SUE 740 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 78212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102717411 | ||||||||
FaxNumber: | 2102719414 | ||||||||
Practice Location | |||||||||
Address1: | 1222 N. MAIN SUE 740 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 78212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102717411 | ||||||||
FaxNumber: | 2102719414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2007 | ||||||||
LastUpdateDate: | 08/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP1600X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Pastoral | 106H00000X | 4828 44622 | TX | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1407710-01 | 05 | TX |   | MEDICAID | 104562 | 01 | TX | VALUES OPTIONS PROVIDER N | OTHER | 4828 44622 | 01 | TX | MFT LICENSURE TEXAS | OTHER |