Healthcare Provider Details

I. General information

NPI: 1902946916
Provider Name (Legal Business Name): STANLEY SELF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 NORTH DICKINSON DRIVE
RUSK TX
75785
US

IV. Provider business mailing address

17844 SUNSET STRIP
FLINT TX
75762-9447
US

V. Phone/Fax

Practice location:
  • Phone: 903-683-3421
  • Fax:
Mailing address:
  • Phone: 903-683-3421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberH4693
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: