=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033506985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACHIEVEMENT, BALANCE, COMMUNITY, PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2015
-----------------------------------------------------
Last Update Date | 09/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 830 PARKER SQ
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-7429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-616-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 830 PARKER SQ
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-7429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-616-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF THERAPY
-----------------------------------------------------
Name | ERICKA KATHLEEN ERVIN
-----------------------------------------------------
Credential | MS, PT
-----------------------------------------------------
Telephone | 214-616-2932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-06-2769
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number | 56129
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 19493
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 56129
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------