=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518350198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERO PSYCHOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2015
-----------------------------------------------------
Last Update Date | 03/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 908 TOWN AND COUNTRY BLVD SUITE 120
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-396-2985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3115 WICHITA ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-7764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-396-2985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. OLIVIA DENISE MCGILL
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 713-396-2985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 35176
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------