Provider Demographics
NPI:1265017636
Name:VITALITY LIFE COUNSELING OF SAN ANTONIO LLC
Entity Type:Organization
Organization Name:VITALITY LIFE COUNSELING OF SAN ANTONIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:210-992-2715
Mailing Address - Street 1:12207 JACOBS POND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5503
Mailing Address - Country:US
Mailing Address - Phone:956-566-7814
Mailing Address - Fax:
Practice Address - Street 1:12207 JACOBS POND
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-5503
Practice Address - Country:US
Practice Address - Phone:956-566-7814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty