Provider Demographics
NPI:1235495607
Name:SPECIALIZED TRANSFORMATION
Entity Type:Organization
Organization Name:SPECIALIZED TRANSFORMATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWERS
Authorized Official - Prefix:
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-601-9519
Mailing Address - Street 1:2305 CORN VALLEY RD
Mailing Address - Street 2:230-4B
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-8804
Mailing Address - Country:US
Mailing Address - Phone:800-601-9519
Mailing Address - Fax:866-326-6765
Practice Address - Street 1:2305 CORN VALLEY RD
Practice Address - Street 2:230-4B
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-8804
Practice Address - Country:US
Practice Address - Phone:800-601-9519
Practice Address - Fax:866-326-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64618101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty