Provider Demographics
NPI:1306020318
Name:ACT PSYCHIATRIC GENETICS CENTER P.A.
Entity Type:Organization
Organization Name:ACT PSYCHIATRIC GENETICS CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BALDERAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-344-0506
Mailing Address - Street 1:84 NE LOOP 410
Mailing Address - Street 2:STE 140
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5860
Mailing Address - Country:US
Mailing Address - Phone:210-344-0506
Mailing Address - Fax:210-344-3512
Practice Address - Street 1:84 NE LOOP 410
Practice Address - Street 2:STE 140
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5860
Practice Address - Country:US
Practice Address - Phone:210-344-0506
Practice Address - Fax:210-344-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL07572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151316001Medicaid
TX151316001Medicaid