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General NPI Number Information
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NPI Number | 1457522104
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Entity Type | Organization
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Legal Business Name | STONEGATE BEHAVIORAL HEALTH, P.C.
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Dates
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Enumeration Date | 03/20/2008
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Last Update Date | 03/20/2008
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Provider Practice Location Address
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Address Line | 4686 BRISTOL TRACE TRL
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City | KELLER
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State | TX
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Zip | 76248-6947
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Country | US
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Telephone | 817-300-1590
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Fax | 817-656-1243
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Provider Business Mailing Address
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Address Line | 4686 BRISTOL TRACE TRL
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City | KELLER
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State | TX
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Zip | 76248-6947
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Country | US
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Telephone | 817-300-1590
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Fax | 817-656-1243
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JOE EASTHAM
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Credential | LMFT, LPC
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Telephone | 817-300-1590
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 59857
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License Number State | TX
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