=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518481456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEVDAS PSYCHOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2017
-----------------------------------------------------
Last Update Date | 08/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 S WHITE CHAPEL BLVD
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-9332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-651-8651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7202 ARCHES AVE
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75063-3556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-371-3462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. NEETHA DEVDAS
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 469-371-3462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 36107
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------