=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073336632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOUGHT VISTA PSYCHIATRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2111 W SWANN AVE STE 204
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33606-2478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-785-7080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3225 MCLEOD DR STE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-2257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | NICOLE SHIRVANI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 216-785-7080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------