Provider Demographics
NPI:1407128218
Name:TKT ENLIGHTENMENT, LLC
Entity Type:Organization
Organization Name:TKT ENLIGHTENMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LYSELL
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-857-8301
Mailing Address - Street 1:17503 LA CANTERA PKWY
Mailing Address - Street 2:SUITE 104, #485
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-8207
Mailing Address - Country:US
Mailing Address - Phone:210-857-8301
Mailing Address - Fax:
Practice Address - Street 1:17720 CORPORATE WOODS DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-3500
Practice Address - Country:US
Practice Address - Phone:210-495-3627
Practice Address - Fax:210-491-3581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM75292084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty