Provider Demographics
NPI:1619044856
Name:RATH, BARRY WILSON (PHD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:WILSON
Last Name:RATH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 S FLEISHEL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2016
Mailing Address - Country:US
Mailing Address - Phone:903-592-6779
Mailing Address - Fax:903-592-7208
Practice Address - Street 1:826 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2016
Practice Address - Country:US
Practice Address - Phone:903-592-6779
Practice Address - Fax:903-592-7208
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23719103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOP23719OtherWORKER'S COMPENSATION
TX0326126 01Medicaid
TX110012100OtherUS DEPARTMENT OF LABOR
TX0326126 01Medicaid
TXOOD21RMedicare UPIN