Provider Demographics
NPI:1891825386
Name:AMISTAD THERAPY CENTER
Entity Type:Organization
Organization Name:AMISTAD THERAPY CENTER
Other - Org Name:DOROTHY W. DUNCAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:830-774-4447
Mailing Address - Street 1:501 W CANTU RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-3056
Mailing Address - Country:US
Mailing Address - Phone:830-774-4447
Mailing Address - Fax:830-774-4265
Practice Address - Street 1:501 W CANTU RD
Practice Address - Street 2:SUITE 400
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-3056
Practice Address - Country:US
Practice Address - Phone:830-774-4447
Practice Address - Fax:830-774-4265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10014251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095504901Medicaid