Provider Demographics
NPI:1457823734
Name:GHOLSON, CLINTON R (LPC)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:R
Last Name:GHOLSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5447 HAWK EYE DR
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163-2255
Mailing Address - Country:US
Mailing Address - Phone:210-392-9520
Mailing Address - Fax:
Practice Address - Street 1:650 SCARBOUROUGH
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78133-4529
Practice Address - Country:US
Practice Address - Phone:830-964-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional