=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770054165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL TESTING SERVICES OF DALLAS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2018
-----------------------------------------------------
Last Update Date | 12/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 PRESTON RD STE 300
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-532-9282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 PRESTON RD STE 300
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-532-9282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICOLE GRANDJEAN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 972-532-9282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------