MEDICARE: CLEANSLATE MEDICAL GROUP OF TEXAS PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM1300X	Multi-Specialty Clinic/Center
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
4	207RA0401X	Addiction Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1487192522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEANSLATE MEDICAL GROUP OF TEXAS PLLC

Provider Business Mailing Address
First Line	:	8 CADILLAC DR STE 180
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-5393
Country	:	US
Telephone Number	:	154-250-0220
Fax Number	:

Provider Business Practice Location Address
First Line	:	2912 KRAFT ST STE 30
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-5410
Country	:	US
Telephone Number	:	413-584-2173
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JESSICA AMICK
Credential	:
Telephone Number	:	727-798-8160

Provider Enumeration Date	:	02/09/2017
Last Update Date	:	03/23/2023

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