=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073714838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR HEALTH PSYCHOLOGY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2007
-----------------------------------------------------
Last Update Date | 05/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10450 BRIAN MOONEY AVE
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-598-6616
-----------------------------------------------------
Fax | 915-598-6651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 370838
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-598-6616
-----------------------------------------------------
Fax | 915-598-6651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/ PRESIDENT
-----------------------------------------------------
Name | DWAYNE D MARROTT
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 915-598-6616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 24316
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------