Provider Demographics
NPI:1750817888
Name:LAKE CONROE COUNSELING CENTER, PLLC
Entity Type:Organization
Organization Name:LAKE CONROE COUNSELING CENTER, PLLC
Other - Org Name:LAKE CONROE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-449-8053
Mailing Address - Street 1:123 BLUE HERON DR STE 104
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-3192
Mailing Address - Country:US
Mailing Address - Phone:936-449-8053
Mailing Address - Fax:
Practice Address - Street 1:123 BLUE HERON DR STE 104
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-3192
Practice Address - Country:US
Practice Address - Phone:936-449-8053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202885106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty