Healthcare Provider Details

I. General information

NPI: 1427666353
Provider Name (Legal Business Name): FRESH START PSYCHIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11455 FALLBROOK DR STE 201
HOUSTON TX
77065-4267
US

IV. Provider business mailing address

1921 DULLES DR
LAFAYETTE LA
70506-2716
US

V. Phone/Fax

Practice location:
  • Phone: 337-223-9487
  • Fax: 888-511-5650
Mailing address:
  • Phone: 373-223-9487
  • Fax: 888-511-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHIAUS SUIRE
Title or Position: OWNER
Credential: CNS
Phone: 512-952-0295