Provider Demographics
NPI:1811242217
Name:FRESH START COUNSELING AND TREATMENT CENTER
Entity type:Organization
Organization Name:FRESH START COUNSELING AND TREATMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPONSOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-365-9534
Mailing Address - Street 1:215 EXECUTIVE WAY STE 140B
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2396
Mailing Address - Country:US
Mailing Address - Phone:972-298-1146
Mailing Address - Fax:972-298-1170
Practice Address - Street 1:215 EXECUTIVE WAY STE 140B
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2396
Practice Address - Country:US
Practice Address - Phone:972-298-1146
Practice Address - Fax:972-298-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000032261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone