Provider Demographics
NPI:1598395345
Name:GRENWELGE, CODY SYLVESTER (LCDC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:SYLVESTER
Last Name:GRENWELGE
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 1:1127 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-3581
Mailing Address - Country:US
Mailing Address - Phone:830-257-3009
Mailing Address - Fax:
Practice Address - Street 1:1127 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-3581
Practice Address - Country:US
Practice Address - Phone:830-257-3009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14955101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)