Healthcare Provider Details

I. General information

NPI: 1386119246
Provider Name (Legal Business Name): POONAM MITTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E ROYAL LN BLDG 3
IRVING TX
75039-3540
US

IV. Provider business mailing address

237 BAY CIR
COPPELL TX
75019-3131
US

V. Phone/Fax

Practice location:
  • Phone: 852-832-5727
  • Fax:
Mailing address:
  • Phone: 856-673-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: