Provider Demographics
NPI:1427405307
Name:SELF EMPLOYEED
Entity type:Organization
Organization Name:SELF EMPLOYEED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT, LPC
Authorized Official - Phone:903-220-3485
Mailing Address - Street 1:2 IRIS ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-1172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 IRIS ARBOR CT
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1172
Practice Address - Country:US
Practice Address - Phone:903-220-3485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201806106H00000X
TX68520101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty