Provider Demographics
NPI:1336702661
Name:REBIRTH COUNSELING, PLLC
Entity Type:Organization
Organization Name:REBIRTH COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:469-608-0295
Mailing Address - Street 1:1100 STONE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-5494
Mailing Address - Country:US
Mailing Address - Phone:466-608-0295
Mailing Address - Fax:
Practice Address - Street 1:1100 STONE RD STE 103
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5494
Practice Address - Country:US
Practice Address - Phone:466-608-0295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-22
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3921009-01Medicaid