Healthcare Provider Details

I. General information

NPI: 1609586817
Provider Name (Legal Business Name): PSYCHFIT360
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8626 TESORO DR STE 490
SAN ANTONIO TX
78217-6217
US

IV. Provider business mailing address

7013 LIONS PARK
SAN ANTONIO TX
78252-1775
US

V. Phone/Fax

Practice location:
  • Phone: 210-202-0100
  • Fax:
Mailing address:
  • Phone: 479-283-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. LAURA E REARDON
Title or Position: LICENSED PSYCHOLOGIST
Credential: PHD
Phone: 479-283-1140