Provider Demographics
NPI:1003323726
Name:FAITHFULLY RESTORED
Entity Type:Organization
Organization Name:FAITHFULLY RESTORED
Other - Org Name:KIMBERLY CLOUGH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:903-918-6574
Mailing Address - Street 1:1010 TRISTAN LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-1862
Mailing Address - Country:US
Mailing Address - Phone:903-918-6574
Mailing Address - Fax:903-704-0980
Practice Address - Street 1:1010 TRISTAN LN
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-1862
Practice Address - Country:US
Practice Address - Phone:903-918-6574
Practice Address - Fax:903-704-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX590131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX373636801Medicaid