Healthcare Provider Details

I. General information

NPI: 1710334107
Provider Name (Legal Business Name): SERINA HUERTA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S LANCASTER RD
DALLAS TX
75216-7167
US

IV. Provider business mailing address

PO BOX 450762
GARLAND TX
75045-0762
US

V. Phone/Fax

Practice location:
  • Phone: 214-857-0534
  • Fax:
Mailing address:
  • Phone: 214-564-3968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number36069
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: