Provider Demographics
NPI:1285005868
Name:DESIDERATA PSYCHOTHERAPY
Entity Type:Organization
Organization Name:DESIDERATA PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:MENA
Authorized Official - Last Name:FUNKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:281-203-1843
Mailing Address - Street 1:17719 BAMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-1852
Mailing Address - Country:US
Mailing Address - Phone:281-203-1842
Mailing Address - Fax:832-616-3460
Practice Address - Street 1:17719 BAMWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-1852
Practice Address - Country:US
Practice Address - Phone:281-203-1842
Practice Address - Fax:832-616-3460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
361789ZH35Medicare UPIN