Healthcare Provider Details

I. General information

NPI: 1538534086
Provider Name (Legal Business Name): PSYCH DIMENSIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W COOPERATIVE WAY STE 110
GEORGETOWN TX
78626-8209
US

IV. Provider business mailing address

2109 MONTICELLO CT
ROUND ROCK TX
78665-5021
US

V. Phone/Fax

Practice location:
  • Phone: 512-535-3777
  • Fax: 512-765-9153
Mailing address:
  • Phone: 512-535-3777
  • Fax: 512-765-9153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RONALD MOORE
Title or Position: PRESIDENT
Credential: FNP
Phone: 512-535-3777