Provider Demographics
NPI:1083260392
Name:INTEGRA PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:INTEGRA PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR-TISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PSYD
Authorized Official - Phone:701-640-9453
Mailing Address - Street 1:611 S HIGHWAY 78 STE 211
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4081
Mailing Address - Country:US
Mailing Address - Phone:972-442-0605
Mailing Address - Fax:
Practice Address - Street 1:611 S HIGHWAY 78 STE 211
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-4081
Practice Address - Country:US
Practice Address - Phone:972-442-0605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)