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NPI Code Detail

MEDICARE: MEDITELECARE OF TEXAS PLLC

MEDICARE: MEDITELECARE OF TEXAS 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
11041C0700XClinical Social Worker
2363LP0808XPsychiatric/Mental Health Nurse Practitioner
32084P0800XPsychiatry Physician
42084P0805XGeriatric Psychiatry Physician
5363L00000XNurse Practitioner
6103T00000XPsychologist

General Provider Information

NPI Number : 1942702238
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEDITELECARE OF TEXAS PLLC
Provider Business Mailing Address
First Line : PO BOX 1595
Second Line :
City : MIDDLETOWN
State : CT
Zip : 06457-8095
Country : US
Telephone Number : 860-788-6404
Fax Number : 860-829-0495
Provider Business Practice Location Address
First Line : 1999 BRYAN ST STE 900
Second Line :
City : DALLAS
State : TX
Zip : 75201-3140
Country : US
Telephone Number : 860-788-6404
Fax Number : 860-829-0495
Authorized Official
Title or Position : CREDENTIALING & ENROLLMENT MANAGER
Name : ANDREA GODFREY
Credential :
Telephone Number : 860-788-6404
Provider Enumeration Date : 03/02/2018
Last Update Date : 09/04/2024

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Directions to “MEDITELECARE OF TEXAS PLLC ” Practice Location

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