Provider Demographics
NPI:1336651579
Name:AUSTIN PSYCHOLOGICAL PRACTICE, PLLC
Entity Type:Organization
Organization Name:AUSTIN PSYCHOLOGICAL PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHESTOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-998-9806
Mailing Address - Street 1:7503 GROVER AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5758 BALCONES DR STE 203
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4274
Practice Address - Country:US
Practice Address - Phone:512-998-9806
Practice Address - Fax:512-861-1985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37124261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)