Provider Demographics
NPI: | 1164621348 |
---|---|
Name: | FARRELL, CARON ELIZABETH (MD, PHD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | CARON |
Middle Name: | ELIZABETH |
Last Name: | FARRELL |
Suffix: | |
Gender: | F |
Credentials: | MD, PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1601 RIO GRANDE ST |
Mailing Address - Street 2: | SUITE 340 |
Mailing Address - City: | AUSTIN |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78701-1137 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 512-324-8960 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3501 MILLS AVE |
Practice Address - Street 2: | SETON MIND INSTITUTE |
Practice Address - City: | AUSTIN |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78731-6309 |
Practice Address - Country: | US |
Practice Address - Phone: | 512-324-9999 |
Practice Address - Fax: | 512-324-2084 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-07-17 |
Last Update Date: | 2013-01-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | N5048 | 2084P0804X, 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 217766901 | Medicaid | |
TX | TXB112470 | Medicare PIN |