Healthcare Provider Details

I. General information

NPI: 1750806311
Provider Name (Legal Business Name): INFINITE POTENTIAL BEHAVIORAL HEALTH SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 SPRING VALLEY RD STE 320
DALLAS TX
75244-3629
US

IV. Provider business mailing address

4100 SPRING VALLEY RD STE 320
DALLAS TX
75244-3629
US

V. Phone/Fax

Practice location:
  • Phone: 214-396-9699
  • Fax: 844-895-4585
Mailing address:
  • Phone: 214-396-9699
  • Fax: 844-895-4585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number34687
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number34687
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number34687
License Number StateTX

VIII. Authorized Official

Name: MS. SHALANDA NICHELLE GORDON
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: PH.D.
Phone: 214-396-9699