Provider Demographics
NPI:1053571554
Name:ENDEAVOR FOR WELLNESS
Entity type:Organization
Organization Name:ENDEAVOR FOR WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KONEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:310-597-0665
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78630-0217
Mailing Address - Country:US
Mailing Address - Phone:512-659-1085
Mailing Address - Fax:
Practice Address - Street 1:1101 ARROW POINT DR
Practice Address - Street 2:SUITE 207
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7739
Practice Address - Country:US
Practice Address - Phone:512-659-1085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201204106H00000X
CAMFC42186106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty