Provider Demographics
NPI:1700382405
Name:MILO, OBETTA (MED, LPC, LCDC)
Entity Type:Individual
Prefix:
First Name:OBETTA
Middle Name:
Last Name:MILO
Suffix:
Gender:F
Credentials:MED, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-3243
Mailing Address - Country:US
Mailing Address - Phone:409-983-4134
Mailing Address - Fax:
Practice Address - Street 1:2750 S 8TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-7719
Practice Address - Country:US
Practice Address - Phone:409-839-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13047101YA0400X
TX74238101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13047OtherLICENSED CHEMICAL DEPENDENCY COUNSELOR