Provider Demographics
NPI:1578701074
Name:SASANO, CAROLYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:SASANO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 AIRPORT FWY STE 205
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-6606
Mailing Address - Country:US
Mailing Address - Phone:817-267-6290
Mailing Address - Fax:817-267-0950
Practice Address - Street 1:1305 AIRPORT FWY STE 205
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6606
Practice Address - Country:US
Practice Address - Phone:817-267-6290
Practice Address - Fax:817-267-0950
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31664103TS0200X
TX34824103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01452126OtherAMERIGROUP
TXTXB148104OtherMEDICARE PTAN NUMBER
TX2140089Medicaid