=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154139202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN PEACOCK, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2024
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 729 N BISHOP AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75208-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-669-3585
-----------------------------------------------------
Fax | 469-991-4796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2026 BERKLEY AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75224-1041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-797-8020
-----------------------------------------------------
Fax | 469-991-4796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP
-----------------------------------------------------
Name | KERI KENDALL
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 214-797-8020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------