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191 W Southlake Blvd Ste 100 Southlake TX 76092-7031 | |
| (817) 488-0502 | |
| (817) 488-0495 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Adult Mental Health |
| Location | 191 W Southlake Blvd Ste 100, Southlake, Texas |
| Authorized Official Name and Position | Jessica Cowdrey (PRACTICE ADMINISTRATOR) |
| Authorized Official Contact | 8174880502 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
191 W Southlake Blvd Ste 100 Southlake TX 76092-7031 Ph: (817) 488-0502 | 191 W Southlake Blvd Ste 100 Southlake TX 76092-7031 Ph: (817) 488-0502 |
| NPI Number | 1285402271 |
|---|---|
| Provider Enumeration Date | 12/19/2023 |
| Last Update Date | 08/06/2024 |
| Certification Date | 08/06/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1285402271 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0850X | Clinic/center - Adult Mental Health | (* (Not Available)) | Primary |
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