=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003672080
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLAY-BASED WELLNESS BEHAVIORAL HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2024
-----------------------------------------------------
Last Update Date | 11/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 N BROOKSIDE DR APT 1315
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-7519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-726-0773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 N ALLEN HEIGHTS DR
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75002-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-726-0773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDING CLINICIAN
-----------------------------------------------------
Name | ANNA OSIPOVA
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 773-726-0773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------