=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124563754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUSTIN PSYCHIATRIC CLINIC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2017
-----------------------------------------------------
Last Update Date | 01/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 W 38TH ST SUITE 421
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78731-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-407-9440
-----------------------------------------------------
Fax | 512-407-9448
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 W 38TH ST SUITE 421
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78731-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-407-9440
-----------------------------------------------------
Fax | 512-407-9448
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BLAYNE HARRIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 512-407-9440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | Q0763
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | Q0763
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------