Provider Demographics
NPI:1194591768
Name:EAST TEXAS LEARNING LAB
Entity type:Organization
Organization Name:EAST TEXAS LEARNING LAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:903-918-3492
Mailing Address - Street 1:1073 COUNTY ROAD 212 E
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-4026
Mailing Address - Country:US
Mailing Address - Phone:903-918-3492
Mailing Address - Fax:
Practice Address - Street 1:1073 COUNTY ROAD 212 E
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-4026
Practice Address - Country:US
Practice Address - Phone:903-918-3492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)