Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 000179 | TX |
NPI | 1003021379 |
---|---|
Provider Name | Mr. Leonard Clarence De Grate JR. |
First Address | Terrell, TX 75161-5350 |
Second Address | Terrell, TX 75161-5350 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2007 |
Last Update Date | 08/07/2007 |