Healthcare Provider Details

I. General information

NPI: 1952888265
Provider Name (Legal Business Name): ELITE PSYCHIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 05/16/2020
Certification Date: 05/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 ARLINGTON HIGHLANDS BLVD STE 200
ARLINGTON TX
76018-6050
US

IV. Provider business mailing address

3901 ARLINGTON HIGHLANDS BLVD STE 200
ARLINGTON TX
76018-6050
US

V. Phone/Fax

Practice location:
  • Phone: 817-695-5035
  • Fax: 817-695-5037
Mailing address:
  • Phone: 817-695-5035
  • Fax: 817-695-5037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberM9770
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. RAVEN ELLIOTT MODISETTE
Title or Position: C.E.O
Credential: FNP-C, PMHNP-BC
Phone: 817-695-5035