Healthcare Provider Details

I. General information

NPI: 1164541488
Provider Name (Legal Business Name): PSYCHIATRIC CONSULTANTS OF FORT WORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 COURTYARD DR STE 330
AUSTIN TX
78731-3334
US

IV. Provider business mailing address

1500 W 38TH ST SUITE 53
AUSTIN TX
78731-6321
US

V. Phone/Fax

Practice location:
  • Phone: 512-377-5000
  • Fax: 512-377-2501
Mailing address:
  • Phone: 512-377-2500
  • Fax: 512-377-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRISTAL LANGE
Title or Position: OFFICE MANAGER
Credential:
Phone: 512-377-2500