Provider Demographics
NPI:1154839470
Name:RESTORE BRAIN, PLLC
Entity Type:Organization
Organization Name:RESTORE BRAIN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CICHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-562-6364
Mailing Address - Street 1:4643 WESTGROVE DR
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3216
Mailing Address - Country:US
Mailing Address - Phone:214-562-6364
Mailing Address - Fax:
Practice Address - Street 1:5207 HERITAGE AVE
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5915
Practice Address - Country:US
Practice Address - Phone:888-990-0663
Practice Address - Fax:888-990-0663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty