Provider Demographics
NPI:1619194537
Name:EAST TEXAS PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:EAST TEXAS PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:936-564-9875
Mailing Address - Street 1:118 E HOSPITAL ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-5203
Mailing Address - Country:US
Mailing Address - Phone:936-564-9875
Mailing Address - Fax:936-564-1902
Practice Address - Street 1:118 E HOSPITAL ST
Practice Address - Street 2:SUITE 300
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-5203
Practice Address - Country:US
Practice Address - Phone:936-564-9875
Practice Address - Fax:936-564-1902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21997103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00QH23Medicare ID - Type Unspecified