Healthcare Provider Details

I. General information

NPI: 1609240977
Provider Name (Legal Business Name): PSYCH MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 PLANO PKWY STE 1401
CARROLLTON TX
75010-5036
US

IV. Provider business mailing address

PO BOX 867443
PLANO TX
75086-7443
US

V. Phone/Fax

Practice location:
  • Phone: 214-888-7711
  • Fax:
Mailing address:
  • Phone: 214-888-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DJILLALI BOUDJENAH
Title or Position: CEO
Credential: MD
Phone: 917-336-8422