Provider Demographics
NPI:1003361635
Name:IKARE MOOD TRAUMA RECOVERY CLINIC
Entity Type:Organization
Organization Name:IKARE MOOD TRAUMA RECOVERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVINDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:267-210-8357
Mailing Address - Street 1:8401 DATAPOINT DR STE 900
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5385
Mailing Address - Country:US
Mailing Address - Phone:210-301-0125
Mailing Address - Fax:844-965-9528
Practice Address - Street 1:8401 DATAPOINT DR STE 900
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5385
Practice Address - Country:US
Practice Address - Phone:210-301-0125
Practice Address - Fax:844-965-9528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ48292084P0800X, 2084P0800X
TXAP129429363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty