Healthcare Provider Details

I. General information

NPI: 1457740862
Provider Name (Legal Business Name): DEEP EDDY PSYCHOTHERAPY MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 DEEP EDDY AVE.
AUSTIN TX
78703
US

IV. Provider business mailing address

508 DEEP EDDY AVE.
AUSTIN TX
78703
US

V. Phone/Fax

Practice location:
  • Phone: 512-956-6463
  • Fax: 512-428-8100
Mailing address:
  • Phone: 512-461-0239
  • Fax: 512-428-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number21274
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number34890
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number34301
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20938
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number33076
License Number StateTX

VIII. Authorized Official

Name: GLENN R. OLDS
Title or Position: MANAGING PSYCHOLOGIST
Credential: PH.D.
Phone: 512-217-9579