Healthcare Provider Details

I. General information

NPI: 1972261311
Provider Name (Legal Business Name): FABIAN AGUIRRE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5454 LA SIERRA DR STE 201
DALLAS TX
75231-2344
US

IV. Provider business mailing address

5454 LA SIERRA DR STE 201
DALLAS TX
75231-2344
US

V. Phone/Fax

Practice location:
  • Phone: 888-923-2256
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number34850
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: