Provider Demographics
NPI:1609389626
Name:ENGEDI THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:ENGEDI THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-867-5811
Mailing Address - Street 1:401 E SONTERRA BLVD STE 375
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4321
Mailing Address - Country:US
Mailing Address - Phone:757-867-5811
Mailing Address - Fax:757-384-1581
Practice Address - Street 1:401 E SONTERRA BLVD STE 375
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4321
Practice Address - Country:US
Practice Address - Phone:757-867-5811
Practice Address - Fax:757-384-1581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006966101YM0800X
261QM0801X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1336489012Medicaid