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General NPI Number Information
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NPI Number | 1801404504
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Entity Type | Organization
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Legal Business Name | OLIVE GREEN BEHAVIORAL HEALTH SERVICES PLLC
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Dates
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Enumeration Date | 07/20/2020
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Last Update Date | 05/20/2022
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Provider Practice Location Address
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Address Line | 201 E DEBBIE LN
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City | MANSFIELD
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State | TX
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Zip | 76063-2924
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Country | US
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Telephone | 682-422-7555
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Fax |
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Provider Business Mailing Address
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Address Line | 539 W COMMERCE ST # 935
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City | DALLAS
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State | TX
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Zip | 75208-1953
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MYRA GAIUS-ANYAEGBU
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Credential |
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Telephone | 682-422-7555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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