MEDICARE: ALLVISION TELEPSYCHIATRY CLINIC 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1659145514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLVISION TELEPSYCHIATRY CLINIC LLC

Provider Business Mailing Address
First Line	:	5125 SUNWOOD CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-6003
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5125 SUNWOOD CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-6003
Country	:	US
Telephone Number	:	405-305-7454
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	PATRICE MICHELLE GARCIA
Credential	:
Telephone Number	:	405-305-7454

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	11/13/2023

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