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1350 E Richards St Tyler TX 75702-6153 | |
| (903) 531-9455 | |
| (903) 526-3118 |
| Full Name | |
|---|---|
| Speciality | Pediatrics |
| Location | 1350 E Richards St, Tyler, Texas |
| Authorized Official Name and Position | Chelsea Cohen (CHIEF OPERATIONS OFFICER) |
| Authorized Official Contact | 9035319455 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1350 E Richards St Tyler TX 75702-6153 Ph: (903) 531-9455 | 1350 E Richards St Tyler TX 75702-6153 Ph: (903) 531-9455 |
| NPI Number | 1336376391 |
|---|---|
| Provider Enumeration Date | 06/17/2009 |
| Last Update Date | 01/08/2025 |
| Certification Date | 01/06/2025 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336376391 | NPI | - | NPPES |
| 203740002 | Other | TX | MEDICAID TH STEPS |
| 203740003 | Other | TX | MEDICAID CSCHN |
| 203740001 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Secondary |
| 208000000X | Pediatrics | (* (Not Available)) | Primary |
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