Provider Demographics
NPI:1871871772
Name:NEELY, JOHN WILLIAM (LCDC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:NEELY
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 WASHINGTON BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-4321
Mailing Address - Country:US
Mailing Address - Phone:409-842-2408
Mailing Address - Fax:409-842-2462
Practice Address - Street 1:4675 WASHINGTON BLVD STE C
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-4321
Practice Address - Country:US
Practice Address - Phone:409-842-2408
Practice Address - Fax:409-842-2462
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03848101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)