=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639568991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBRANT MINDS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2015
-----------------------------------------------------
Last Update Date | 01/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10711 BURNET RD SUITE 321
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-4478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-944-5856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10711 BURNET RD SUITE 321
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-4478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO
-----------------------------------------------------
Name | KAREN SEROUSSI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-944-5856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------