Provider Demographics
NPI:1487192522
Name:CLEANSLATE MEDICAL GROUP OF TEXAS PLLC
Entity Type:Organization
Organization Name:CLEANSLATE MEDICAL GROUP OF TEXAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-798-8160
Mailing Address - Street 1:8 CADILLAC DR STE 180
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5393
Mailing Address - Country:US
Mailing Address - Phone:154-250-0220
Mailing Address - Fax:
Practice Address - Street 1:2912 KRAFT ST STE 30
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-5410
Practice Address - Country:US
Practice Address - Phone:413-584-2173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty