Provider Demographics
NPI:1578185401
Name:IMPACT PSYCHIATRY PC
Entity Type:Organization
Organization Name:IMPACT PSYCHIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:
Authorized Official - Last Name:OSAWARU
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP-BC
Authorized Official - Phone:214-677-0224
Mailing Address - Street 1:2080 N STATE HIGHWAY 360 STE 236
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-1467
Mailing Address - Country:US
Mailing Address - Phone:214-677-0224
Mailing Address - Fax:
Practice Address - Street 1:2080 N STATE HIGHWAY 360 STE 236
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1467
Practice Address - Country:US
Practice Address - Phone:214-677-0224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty