Provider Demographics
NPI:1861789141
Name:POULAKIS, MARGARITA DIANA (MA, CRC, LCDC)
Entity type:Individual
Prefix:
First Name:MARGARITA
Middle Name:DIANA
Last Name:POULAKIS
Suffix:
Gender:F
Credentials:MA, CRC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E SONTERRA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4073
Mailing Address - Country:US
Mailing Address - Phone:210-560-7278
Mailing Address - Fax:
Practice Address - Street 1:401 E SONTERRA BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4073
Practice Address - Country:US
Practice Address - Phone:210-560-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX12180101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1306421Medicaid
MAM18684OtherBLUE CROSS OF MASS
MA1308785Medicaid
MAY10400Medicare PIN