Provider Demographics
NPI:1578807533
Name:EASTER SEALS NORTH TEXAS
Entity Type:Organization
Organization Name:EASTER SEALS NORTH TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-759-7931
Mailing Address - Street 1:1900 ELM ST
Mailing Address - Street 2:# 810
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4527
Mailing Address - Country:US
Mailing Address - Phone:972-939-3911
Mailing Address - Fax:972-394-6266
Practice Address - Street 1:1900 ELM ST
Practice Address - Street 2:# 810
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4527
Practice Address - Country:US
Practice Address - Phone:972-939-3911
Practice Address - Fax:972-394-6266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11212253103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty