Provider Demographics
NPI:1588823199
Name:OUR LADY OF THE LAKE UNIVERSITY
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE UNIVERSITY
Other - Org Name:COMMUNITY COUNSELING SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SOLORZANO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:210-434-1054
Mailing Address - Street 1:590 N GENERAL MCMULLEN
Mailing Address - Street 2:3
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228-6205
Mailing Address - Country:US
Mailing Address - Phone:210-434-1054
Mailing Address - Fax:210-434-1380
Practice Address - Street 1:590 N GENERAL MCMULLEN
Practice Address - Street 2:3
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-6205
Practice Address - Country:US
Practice Address - Phone:210-434-1054
Practice Address - Fax:210-434-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62520101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144674201Medicaid