Provider Demographics
NPI:1447700166
Name:P.E.E.R. PALS, LLC
Entity type:Organization
Organization Name:P.E.E.R. PALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRAVETT
Authorized Official - Middle Name:ROBINSON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:713-724-3603
Mailing Address - Street 1:200 W 2ND ST
Mailing Address - Street 2:228-A
Mailing Address - City:FREEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:77541-5773
Mailing Address - Country:US
Mailing Address - Phone:713-724-3603
Mailing Address - Fax:
Practice Address - Street 1:200 W 2ND ST
Practice Address - Street 2:228-A
Practice Address - City:FREEPORT
Practice Address - State:TX
Practice Address - Zip Code:77541-5773
Practice Address - Country:US
Practice Address - Phone:713-724-3603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:P.E.E.R. PALS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68632251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX325808902Medicaid