Healthcare Provider Details

I. General information

NPI: 1265964407
Provider Name (Legal Business Name): FLOWER MOUND BRAIN TRAINING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 BERKSHIRE CT
PROSPER TX
75078-0779
US

IV. Provider business mailing address

2021 JUSTIN RD STE 249
FLOWER MOUND TX
75028-3834
US

V. Phone/Fax

Practice location:
  • Phone: 469-270-0700
  • Fax:
Mailing address:
  • Phone: 469-464-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: GABE CHAMBERS
Title or Position: PRESIDENT
Credential:
Phone: 469-270-0700