Provider Demographics
NPI:1639703143
Name:OPTIMAL THERAPEUTIC SERVICES, PLLC
Entity Type:Organization
Organization Name:OPTIMAL THERAPEUTIC SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARNEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUTCHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-338-4711
Mailing Address - Street 1:12650 N. BEACH STREET
Mailing Address - Street 2:SUITE 114, #204
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244
Mailing Address - Country:US
Mailing Address - Phone:832-338-4711
Mailing Address - Fax:
Practice Address - Street 1:4425 W AIRPORT FWY STE 122
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-5817
Practice Address - Country:US
Practice Address - Phone:817-409-4640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1235322801Medicaid