=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467892810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AR PSYCHOLOGICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2013
-----------------------------------------------------
Last Update Date | 07/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 231 E SOUTHLAKE BLVD SUITE 140
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-720-3118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 231 E SOUTHLAKE BLVD SUITE 140
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-720-3118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. AMANPREET RANDAZZO
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 908-720-3118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 34091
-----------------------------------------------------
License Number State |
-----------------------------------------------------