Healthcare Provider Details

I. General information

NPI: 1770060691
Provider Name (Legal Business Name): ELITE PSYCHIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 04/04/2020
Certification Date: 04/04/2020
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 TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberM9770
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberM9770
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberM9770
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberM9770
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberM9770
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP137299
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP137299
License Number StateTX
# 11
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM9770
License Number StateTX

VIII. Authorized Official

Name: RAVEN MODISETTE
Title or Position: CEO
Credential: FNP-C, PMHNP-BC
Phone: 817-695-5035