=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063306942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENTLE MENTAL TREATMENT CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2025
-----------------------------------------------------
Last Update Date | 06/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1771 CRESTRIDGE CIR
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75407-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-307-2531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1771 CRESTRIDGE CIR
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75407-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-307-2531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DOMIKAH OLATERU-OLAGBEGI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-307-2531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------