1154681740 NPI number — SBN PROFESSIONAL PSYCHIATRY COORPORATION

Table of content: MRS. HEIDI COLLEEN IVANOVICH LMT (NPI 1457242471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154681740 NPI number — SBN PROFESSIONAL PSYCHIATRY COORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SBN PROFESSIONAL PSYCHIATRY COORPORATION
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:
1154681740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5402 REMINGTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75044-5590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-244-2625
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5402 REMINGTON DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-244-2625
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
AZIZ
Authorized Official First Name:
BUSHRA
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
214-244-2625

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  P2949 , 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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