=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730725995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW BALANCE PSYCHOLOGICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2019
-----------------------------------------------------
Last Update Date | 11/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 N TRAVIS ST STE 305
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-5999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-607-9980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5313 CORNERSTONE DR
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-6490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-344-6535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JENNA A MILLER
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 773-344-6535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------