Healthcare Provider Details

I. General information

NPI: 1699945360
Provider Name (Legal Business Name): SUMMIT MENTAL HEALTH CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 SPICEWOOD SPRINGS RD BLDG#L, #2
AUSTIN TX
78759-8661
US

IV. Provider business mailing address

PO BOX 17906
AUSTIN TX
78760-7906
US

V. Phone/Fax

Practice location:
  • Phone: 512-732-2122
  • Fax:
Mailing address:
  • Phone: 512-732-2122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberL1620
License Number StateTX

VIII. Authorized Official

Name: DR. FRANCISCA ADA IFESINACHUKWU
Title or Position: MEDICAL DIRECTOR/PRESIDENT
Credential: M.D.
Phone: 512-732-2122