Provider Demographics
NPI:1750046074
Name:KSA ADDICTION TREATMENT LLC
Entity Type:Organization
Organization Name:KSA ADDICTION TREATMENT LLC
Other - Org Name:LCDC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED CHEMICAL DEPENDENCY
Authorized Official - Prefix:
Authorized Official - First Name:MYLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON-SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:469-321-1346
Mailing Address - Street 1:132 HILLSIDE LN
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-5910
Mailing Address - Country:US
Mailing Address - Phone:469-321-1346
Mailing Address - Fax:
Practice Address - Street 1:132 HILLSIDE LN
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-5910
Practice Address - Country:US
Practice Address - Phone:469-321-1346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty