| Desta Therapy, Llc | |
|
16607 Blanco Rd Ste 12103 San Antonio TX 78232-1961 | |
| (210) 417-9272 | |
| Not Available |
| Full Name | Desta Therapy, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 16607 Blanco Rd Ste 12103, San Antonio, Texas |
| Authorized Official Name and Position | James Gross (CO-FOUNDER/MANAGING PARTNER) |
| Authorized Official Contact | 2104179272 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Desta Therapy, Llc 405 El Portal Dr San Antonio TX 78232-2003 Ph: (210) 417-9272 | Desta Therapy, Llc 16607 Blanco Rd Ste 12103 San Antonio TX 78232-1961 Ph: (210) 417-9272 |
| NPI Number | 1891529673 |
|---|---|
| Provider Enumeration Date | 08/26/2024 |
| Last Update Date | 08/26/2024 |
| Certification Date | 08/26/2024 |
| Medicare PECOS PAC ID | 8224566708 |
|---|---|
| Medicare Enrollment ID | O20250113000022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1891529673 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Jessica Kirby Gomez-pool |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1083202709 PECOS PAC ID: 2961855507 Enrollment ID: I20240130002546 |
| Provider Name | Nichole Mcdaniel |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1770326092 PECOS PAC ID: 3577097294 Enrollment ID: I20241118000065 |
| Provider Name | Nicole Larsen |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1639891161 PECOS PAC ID: 1456875525 Enrollment ID: I20250410000705 |
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