=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164863189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORY CLINIC OF TEXAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2013
-----------------------------------------------------
Last Update Date | 08/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8330 MEADOW RD SUITE 219
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75231-3767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-691-5199
-----------------------------------------------------
Fax | 214-890-7730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8330 MEADOW RD SUITE 219
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75231-3767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-691-5199
-----------------------------------------------------
Fax | 214-890-7730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAMES B HARRIS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 214-691-5199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 23774
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------