Provider Demographics
NPI:1114285970
Name:EAST TEXAS NEUROBEHAVIORAL HEALTH,PLLC
Entity Type:Organization
Organization Name:EAST TEXAS NEUROBEHAVIORAL HEALTH,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:903-887-0697
Mailing Address - Street 1:PO BOX 2107
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75147-5017
Mailing Address - Country:US
Mailing Address - Phone:903-887-0697
Mailing Address - Fax:903-887-0698
Practice Address - Street 1:122 S GUN BARREL LN
Practice Address - Street 2:SUITE 6
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-9403
Practice Address - Country:US
Practice Address - Phone:903-887-0697
Practice Address - Fax:903-887-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33829103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty