Provider Demographics
NPI:1144642968
Name:KINGDOM PSYCHOTHERAPY AND WELLNESS
Entity type:Organization
Organization Name:KINGDOM PSYCHOTHERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARRIAGE AND FAMILY THERAP
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHON
Authorized Official - Middle Name:MARICIA
Authorized Official - Last Name:SUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LPC
Authorized Official - Phone:210-540-3025
Mailing Address - Street 1:18534 FORTY-SIX PARKWAY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070
Mailing Address - Country:US
Mailing Address - Phone:210-540-3025
Mailing Address - Fax:210-568-2113
Practice Address - Street 1:1027 OAK TURN
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-2663
Practice Address - Country:US
Practice Address - Phone:210-540-3025
Practice Address - Fax:210-568-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20148101YP2500X
TX202026106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty