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NPI Code Detail

MEDICARE: OLIVE GREEN BEHAVIORAL HEALTH SERVICES PLLC

MEDICARE: OLIVE GREEN BEHAVIORAL HEALTH SERVICES PLLC
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number : 1801404504
Entity Type Code : Organization
Provider Name (Legal Business Name) : OLIVE GREEN BEHAVIORAL HEALTH SERVICES PLLC
Provider Business Mailing Address
First Line : 539 W COMMERCE ST # 935
Second Line :
City : DALLAS
State : TX
Zip : 75208-1953
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 201 E DEBBIE LN
Second Line :
City : MANSFIELD
State : TX
Zip : 76063-2924
Country : US
Telephone Number : 682-422-7555
Fax Number :
Authorized Official
Title or Position : CEO
Name : MYRA GAIUS-ANYAEGBU
Credential :
Telephone Number : 682-422-7555
Provider Enumeration Date : 07/20/2020
Last Update Date : 05/20/2022

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