Healthcare Provider Details

I. General information

NPI: 1164890141
Provider Name (Legal Business Name): SDS PSYCHIATRIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 CLINIC DR
LONGVIEW TX
75605-5172
US

IV. Provider business mailing address

PO BOX 2922
LONGVIEW TX
75606-2922
US

V. Phone/Fax

Practice location:
  • Phone: 903-212-3105
  • Fax:
Mailing address:
  • Phone: 903-331-0506
  • Fax: 903-331-0462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAUNA DESAI SHAH
Title or Position: OWNER/PROVIDER
Credential:
Phone: 903-331-0506