Provider Demographics
NPI:1093260002
Name:SPEARHEAD LODGE, LLC
Entity Type:Organization
Organization Name:SPEARHEAD LODGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MS,LCDC
Authorized Official - Phone:972-835-1963
Mailing Address - Street 1:8455 LYNDON LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-3704
Mailing Address - Country:US
Mailing Address - Phone:512-278-4940
Mailing Address - Fax:
Practice Address - Street 1:8455 LYNDON LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-3704
Practice Address - Country:US
Practice Address - Phone:512-278-4940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4085-4086101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty