Provider Demographics
NPI:1467694935
Name:MEDI-PSYCH E & M, LLC
Entity Type:Organization
Organization Name:MEDI-PSYCH E & M, LLC
Other - Org Name:MEDIPSYCH COUNSELING ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AUTHORIZED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DISNARD
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, MPH, ARNP-BC
Authorized Official - Phone:817-694-4978
Mailing Address - Street 1:3115 FORT WORTH HWY
Mailing Address - Street 2:# 200
Mailing Address - City:HUDSON OAKS
Mailing Address - State:TX
Mailing Address - Zip Code:76087-8720
Mailing Address - Country:US
Mailing Address - Phone:817-694-4978
Mailing Address - Fax:817-448-9088
Practice Address - Street 1:3115 FORT WORTH HWY
Practice Address - Street 2:# 200
Practice Address - City:HUDSON OAKS
Practice Address - State:TX
Practice Address - Zip Code:76087-8720
Practice Address - Country:US
Practice Address - Phone:817-694-4978
Practice Address - Fax:817-448-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9274840363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1366443822OtherNPI INDIVIDUAL
TX8A9182Medicare PIN
TXP93581Medicare UPIN