=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265931349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAMONA DIANE BURROUGHS PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2018
-----------------------------------------------------
Last Update Date | 06/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 MONTGOMERY ST FL 4
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-735-2322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3309 TAMARACK LN
-----------------------------------------------------
City | ARGYLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76226-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-368-2298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 36858
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------