=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477066512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TABULA RASA PSYCHOLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2017
-----------------------------------------------------
Last Update Date | 08/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2636 S LOOP W #550-A
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-698-0141
-----------------------------------------------------
Fax | 281-605-6722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2636 S LOOP W #550-A
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-698-0141
-----------------------------------------------------
Fax | 281-605-6722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | DR. BLYTHE TWOSISTERS
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 214-997-4697
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 36566
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------