1902154461 NPI number — MY FAMILY THERAPY

Table of content: (NPI 1902154461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902154461 NPI number — MY FAMILY THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY FAMILY THERAPY
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:
1902154461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6800 W GATE BLVD # 132-617
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78745-4883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-853-9864
Provider Business Mailing Address Fax Number:
866-586-3938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8700 MANCHACA RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78748-5372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-853-9864
Provider Business Practice Location Address Fax Number:
866-586-3938
Provider Enumeration Date:
08/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
NERICCIO
Authorized Official First Name:
MARY ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
SPEECH LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
512-853-9864

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  10310 , 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: 191681904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com