Healthcare Provider Details

I. General information

NPI: 1154970085
Provider Name (Legal Business Name): NORTH TEXAS ADOLESCENT AND YOUNG ADULT PSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8668 JOHN HICKMAN PKWY STE 601
FRISCO TX
75034-9385
US

IV. Provider business mailing address

PO BOX 250913
PLANO TX
75025-0913
US

V. Phone/Fax

Practice location:
  • Phone: 972-299-0127
  • Fax: 844-809-6223
Mailing address:
  • Phone: 972-299-0127
  • Fax: 844-809-6223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. WADE C MCDONALD
Title or Position: CLINICAL DIRECTOR
Credential: PHD
Phone: 214-763-9595