1881780419 NPI number — ALICE MARIE CASTLEBERRY PSYD

Table of content: ALICE MARIE CASTLEBERRY PSYD (NPI 1881780419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881780419 NPI number — ALICE MARIE CASTLEBERRY PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTLEBERRY
Provider First Name:
ALICE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEUBAUER
Provider Other First Name:
ALICE
Provider Other Middle Name:
CASTLEBERRY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881780419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2536
Provider Second Line Business Mailing Address:
PO BOX 561
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75751-7536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-928-5299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 EARL GARRETT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-4514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-522-2547
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  32485 , 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)

  • Identifier: 171650802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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