| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology - Psychiatry |
| Location | 213a Old Hewitt Rd, Waco, Texas |
| Authorized Official Name and Position | Melanie B Illich (PRESIDENT) |
| Authorized Official Contact | 2547722006 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 23289 Waco TX 76702 Ph: (254) 772-2006 | 213a Old Hewitt Rd Waco TX 76712 Ph: (254) 772-2006 |
| NPI Number | 1699879288 |
|---|---|
| Provider Enumeration Date | 09/12/2006 |
| Last Update Date | 11/26/2013 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699879288 | NPI | - | NPPES |
| 113408204 | Medicaid | TX | |
| 157845201 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | J2104 (Texas) | Primary |
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