Healthcare Provider Details

I. General information

NPI: 1770082745
Provider Name (Legal Business Name): PERFORMANCE NEUROPSYCHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 AVON LN STE 285
FRISCO TX
75033-1609
US

IV. Provider business mailing address

PO BOX 6001
FRISCO TX
75035
US

V. Phone/Fax

Practice location:
  • Phone: 972-632-0033
  • Fax: 214-501-0809
Mailing address:
  • Phone: 469-400-6230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number34011
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number34011
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number34011
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number34011
License Number StateTX

VIII. Authorized Official

Name: MARK THOMAS BARISA
Title or Position: NEUROPSYCHOLOGIST
Credential: PHD
Phone: 469-400-6230