Healthcare Provider Details

I. General information

NPI: 1417730631
Provider Name (Legal Business Name): CUSTOMMADEIMAGEHEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 WATTERS CREEK BLVD STE 250
ALLEN TX
75013-3770
US

IV. Provider business mailing address

1972 SUNNY SIDE DR
LITTLE ELM TX
75068-7803
US

V. Phone/Fax

Practice location:
  • Phone: 214-945-3702
  • Fax:
Mailing address:
  • Phone: 214-797-8767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TONYA WILLIAMS
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 214-945-3702