Basic Information
| Provider Information | |||||||||
| NPI: | 1487767588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALAS | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | ANGEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 228 SAINT GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306726511 | ||||||||
| FaxNumber: | 8306726430 | ||||||||
| Practice Location | |||||||||
| Address1: | 228 SAINT GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306726511 | ||||||||
| FaxNumber: | 8306726430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 32524 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 32524 | 01 | TX | ST. BD. OF EXAM OF PSY | OTHER |