1114285970 NPI number — EAST TEXAS NEUROBEHAVIORAL HEALTH,PLLC

Table of content: (NPI 1114285970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114285970 NPI number — EAST TEXAS NEUROBEHAVIORAL HEALTH,PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS NEUROBEHAVIORAL HEALTH,PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114285970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MABANK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75147-5017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-887-0697
Provider Business Mailing Address Fax Number:
903-887-0698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 S GUN BARREL LN
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
GUN BARREL CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75156-9403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-887-0697
Provider Business Practice Location Address Fax Number:
903-887-0698
Provider Enumeration Date:
05/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GARD
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
903-887-0697

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  33829 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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