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General NPI Number Information
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NPI Number | 1053287045
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Entity Type | Organization
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Legal Business Name | IDERA BEHAVIORAL HEALTH PLLC
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Dates
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Enumeration Date | 10/15/2025
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Last Update Date | 10/15/2025
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Provider Practice Location Address
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Address Line | 3036 LARRETA
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City | GRAND PRAIRIE
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State | TX
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Zip | 75054-6794
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Country | US
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Telephone | 817-217-0662
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Fax |
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Provider Business Mailing Address
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Address Line | 3036 LARRETA
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City | GRAND PRAIRIE
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State | TX
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Zip | 75054-6794
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Country | US
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Telephone | 817-217-0662
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | BABATUNDE SHITTU
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Credential | PMHNP-BC
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Telephone | 817-217-0662
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number |
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License Number State |
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