Provider Demographics
NPI:1740458421
Name:IDENTITY DEVELOPMENT COUNSELING AND FAMILY RESOURCE CENTER
Entity type:Organization
Organization Name:IDENTITY DEVELOPMENT COUNSELING AND FAMILY RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:KOINER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC LMFT NCC
Authorized Official - Phone:210-490-9062
Mailing Address - Street 1:21714 HARDY OAK
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-490-9062
Mailing Address - Fax:210-490-8843
Practice Address - Street 1:21714 HARDY OAK
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-490-9062
Practice Address - Fax:210-490-8843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX001123101YP2500X
TX000552106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8440LOtherBCBS
A112102OtherVALUE OPTIONS
0003OtherTRI CARE
=========OtherUNITED HEALTH CARE
=========OtherUBH
8440LOtherBCBS
=========OtherCIGNA