MEDICARE: DALLAS PSYCHOLOGY GROUP

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1659732717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DALLAS PSYCHOLOGY GROUP

Provider Business Mailing Address
First Line	:	11551 FOREST CENTRAL DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-3920
Country	:	US
Telephone Number	:	469-751-2623
Fax Number	:

Provider Business Practice Location Address
First Line	:	11551 FOREST CENTRAL DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-3920
Country	:	US
Telephone Number	:	469-751-2623
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	WENDY BATES
Credential	:
Telephone Number	:	46961975081

Provider Enumeration Date	:	03/16/2016
Last Update Date	:	03/16/2016

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