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General NPI Number Information
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NPI Number | 1447708128
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Entity Type | Organization
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Legal Business Name | CLEARLAKE KIDS PSYCHIATRY
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Dates
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Enumeration Date | 09/12/2016
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Last Update Date | 09/05/2017
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Provider Practice Location Address
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Address Line | 17226 MERCURY DR SUITE 100
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City | HOUSTON
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State | TX
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Zip | 77058-2792
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Country | US
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Telephone | 281-975-0600
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Fax |
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Provider Business Mailing Address
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Address Line | 17226 MERCURY DR SUITE 100
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City | HOUSTON
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State | TX
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Zip | 77058-2792
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Country | US
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Telephone | 281-975-0600
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JEANNE RUSSELL
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Credential | PA-C
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Telephone | 903-918-3294
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA00473
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License Number State | TX
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