MEDICARE: MEDI-PSYCH E & M, LLC

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	ARNP9274840	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1366443822	OTHER	TX	NPI INDIVIDUAL

General Provider Information

NPI Number	:	1467694935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDI-PSYCH E & M, LLC

Provider Business Mailing Address
First Line	:	3115 FORT WORTH HWY
Second Line	:	# 200
City	:	HUDSON OAKS
State	:	TX
Zip	:	76087-8720
Country	:	US
Telephone Number	:	817-694-4978
Fax Number	:	817-448-9088

Provider Business Practice Location Address
First Line	:	3115 FORT WORTH HWY
Second Line	:	# 200
City	:	HUDSON OAKS
State	:	TX
Zip	:	76087-8720
Country	:	US
Telephone Number	:	817-694-4978
Fax Number	:	817-448-9088

Authorized Official
Title or Position	:	OWNER/AUTHORIZED AGENT
Name	:	MS. GERALDINE M DISNARD
Credential	:	MSN, MPH, ARNP-BC
Telephone Number	:	817-694-4978

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	11/04/2010

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Directions to “MEDI-PSYCH E & M, LLC ” Practice Location

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