Provider Demographics
NPI:1619645975
Name:THE EXTENDED OLIVE BRANCH COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:THE EXTENDED OLIVE BRANCH COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:T
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-443-0553
Mailing Address - Street 1:16320 HUEBNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1690
Mailing Address - Country:US
Mailing Address - Phone:830-443-0553
Mailing Address - Fax:
Practice Address - Street 1:16320 HUEBNER RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-1690
Practice Address - Country:US
Practice Address - Phone:830-443-0553
Practice Address - Fax:830-215-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-01
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty