Provider Demographics
NPI:1376954263
Name:SRP BEHAVIORAL HOSPITAL OF PLANO LLC
Entity Type:Organization
Organization Name:SRP BEHAVIORAL HOSPITAL OF PLANO LLC
Other - Org Name:WELLBRIDGE HEALTHCARE OF PLANO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-635-4748
Mailing Address - Street 1:8343 DOUGLAS AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-5887
Mailing Address - Country:US
Mailing Address - Phone:972-596-5445
Mailing Address - Fax:972-596-2332
Practice Address - Street 1:4301 MAPLESHADE LANE
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-0010
Practice Address - Country:US
Practice Address - Phone:972-596-5445
Practice Address - Fax:972-596-2332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100264283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454130Medicare Oscar/Certification
TX454130Medicare Oscar/Certification