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General NPI Number Information
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NPI Number | 1528810439
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Entity Type | Organization
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Legal Business Name | WITS SPECIALTY CLINIC PLLC
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Dates
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Enumeration Date | 04/03/2024
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Last Update Date | 04/03/2024
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Provider Practice Location Address
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Address Line | 9000 TESORO DR STE 103
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City | SAN ANTONIO
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State | TX
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Zip | 78217-6100
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Country | US
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Telephone | 210-322-0191
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Fax |
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Provider Business Mailing Address
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Address Line | 9422 COPPERWAY
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City | CONVERSE
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State | TX
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Zip | 78109-2063
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Country | US
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Telephone | 210-322-0191
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Fax |
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Authorized Official
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Title or Position | OWNER/ NP
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Name | MS. AUDREY MOODY
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Credential | NP
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Telephone | 210-322-0191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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