=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538981691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESTIGE HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2024
-----------------------------------------------------
Last Update Date | 05/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4312 S MALCOLM X BLVD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75215-4307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-844-5325
-----------------------------------------------------
Fax | 214-602-2687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4312 S MALCOLM X BLVD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75215-4307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-844-5325
-----------------------------------------------------
Fax | 214-602-2687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | WHITNEY STOVALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-844-5325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------