Provider Demographics
NPI:1093595845
Name:C.T. DEEP IMPACT LLC
Entity Type:Organization
Organization Name:C.T. DEEP IMPACT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:210-343-5107
Mailing Address - Street 1:3100 S W S YOUNG DR # 10333
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-2001
Mailing Address - Country:US
Mailing Address - Phone:210-343-5107
Mailing Address - Fax:
Practice Address - Street 1:3100 S W S YOUNG DR # 10333
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-2001
Practice Address - Country:US
Practice Address - Phone:210-343-5107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty