Healthcare Provider Details

I. General information

NPI: 1487192522
Provider Name (Legal Business Name): CLEANSLATE MEDICAL GROUP OF TEXAS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2912 KRAFT ST STE 30
ARLINGTON TX
76010-5410
US

IV. Provider business mailing address

8 CADILLAC DR STE 180
BRENTWOOD TN
37027-5393
US

V. Phone/Fax

Practice location:
  • Phone: 413-584-2173
  • Fax:
Mailing address:
  • Phone: 154-250-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA AMICK
Title or Position: DIRECTOR
Credential:
Phone: 727-798-8160