Healthcare Provider Details

I. General information

NPI: 1447672910
Provider Name (Legal Business Name): SRP BEHAVIORAL HOSPITAL OF FORT WORTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 OVERTON RIDGE BLVD
FORT WORTH TX
76132-0000
US

IV. Provider business mailing address

8343 DOUGLAS AVE STE 350
DALLAS TX
75225-5887
US

V. Phone/Fax

Practice location:
  • Phone: 817-361-1991
  • Fax: 817-361-1993
Mailing address:
  • Phone: 817-361-1991
  • Fax: 817-361-1993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number100246
License Number StateTX

VIII. Authorized Official

Name: BARBARA SHOUSE
Title or Position: DELEGATED/AUTHORIZED OFFICIAL
Credential:
Phone: 502-680-2115