=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790399863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EZ MIND PSYCHIATRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2020
-----------------------------------------------------
Last Update Date | 02/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2770 MAIN ST STE 119
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-4336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-632-6040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3751 MAIN ST STE 600
-----------------------------------------------------
City | THE COLONY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75056-4138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-632-6040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | KEVIN J PETER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-868-6944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------