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General NPI Number Information
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NPI Number | 1851129654
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Entity Type | Organization
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Legal Business Name | BEACON BEHAVIORAL OF TEXAS PA
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Dates
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Enumeration Date | 07/23/2024
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Last Update Date | 07/23/2024
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Provider Practice Location Address
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Address Line | 1901 MEDI PARK DR STE 2058
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City | AMARILLO
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State | TX
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Zip | 79106-2109
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Country | US
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Telephone | 806-354-9540
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Fax |
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Provider Business Mailing Address
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Address Line | 22 PRESTIGE CIR STE 200
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City | ALLEN
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State | TX
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Zip | 75002-3441
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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 | CREDENTIALING SUPERVISOR
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Name | KIMBERLY GLAVESKAS
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Credential |
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Telephone | 214-550-7536
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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