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General NPI Number Information
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NPI Number | 1568265205
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Entity Type | Organization
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Legal Business Name | MIP SA LLC
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Dates
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Enumeration Date | 03/28/2025
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 901 NE LOOP 410 # 405
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City | SAN ANTONIO
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State | TX
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Zip | 78209-1305
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Country | US
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Telephone | 210-926-5502
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Fax |
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Provider Business Mailing Address
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Address Line | 901 NE LOOP 410 # 405
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City | SAN ANTONIO
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State | TX
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Zip | 78209-1305
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Country | US
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Telephone | 210-926-5502
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. DINA KUSHALIYEVA
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Credential |
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Telephone | 214-802-0224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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