Provider Demographics
NPI:1306181185
Name:ADD LIFE MENTORING OF VICTORIA
Entity Type:Organization
Organization Name:ADD LIFE MENTORING OF VICTORIA
Other - Org Name:ADD LIFE MENTORING OF VICTORIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ISIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-571-9727
Mailing Address - Street 1:3308 BOBOLINK ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-7612
Mailing Address - Country:US
Mailing Address - Phone:713-571-9727
Mailing Address - Fax:281-829-7236
Practice Address - Street 1:3308 BOBOLINK ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-7612
Practice Address - Country:US
Practice Address - Phone:713-571-9727
Practice Address - Fax:281-829-7236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty