Basic Information
| Provider Information | |||||||||
| NPI: | 1407128218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TKT ENLIGHTENMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17503 LA CANTERA PKWY | ||||||||
| Address2: | SUITE 104, #485 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782578207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108578301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17720 CORPORATE WOODS DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782593500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104953627 | ||||||||
| FaxNumber: | 2104913581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2012 | ||||||||
| LastUpdateDate: | 05/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | POLK | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | LYSELL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2108578301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | M7529 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.