MEDICARE: DALLAS LEIGH UPCHURCH PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	10009760	OR
2	363L00000X	Nurse Practitioner	10009760	OR

General Provider Information

NPI Number	:	1013551233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALLAS LEIGH UPCHURCH PMHNP

Provider Business Mailing Address
First Line	:	821 KENDRA DR
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76502-5878
Country	:	US
Telephone Number	:	706-326-6088
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 VETERANS MEMORIAL DR
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76504-7451
Country	:	US
Telephone Number	:	254-778-4811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2019
Last Update Date	:	03/23/2026

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