Healthcare Provider Details

I. General information

NPI: 1669195202
Provider Name (Legal Business Name): INTEGRATIVE PSYCHIATRY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ELLIOTT AVE W STE 500
SEATTLE WA
98119-4292
US

IV. Provider business mailing address

708 CLEMENT DR
CEDAR HILL TX
75104-7352
US

V. Phone/Fax

Practice location:
  • Phone: 469-321-9543
  • Fax: 682-227-2030
Mailing address:
  • Phone: 469-321-9543
  • Fax: 682-227-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. ETIENNE CLEMENT POUFONG
Title or Position: PMHNP
Credential:
Phone: 469-321-9543