MEDICARE: LIVING SPRING FAMILY PSYCHIATRY

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

General Provider Information

NPI Number	:	1588400709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING SPRING FAMILY PSYCHIATRY

Provider Business Mailing Address
First Line	:	811 W JEFFERSON ST
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1645
Country	:	US
Telephone Number	:	214-662-2675
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 W JEFFERSON ST
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1645
Country	:	US
Telephone Number	:	214-662-2675
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. OLUSHOLA A BALOGUN
Credential	:	NP
Telephone Number	:	214-662-2675

Provider Enumeration Date	:	07/08/2024
Last Update Date	:	09/06/2024

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