Provider Demographics
NPI:1740767607
Name:CLEAR WATER PSYCHIATRY & WELLNESS
Entity Type:Organization
Organization Name:CLEAR WATER PSYCHIATRY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TORI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-203-3588
Mailing Address - Street 1:1600 W 38TH ST STE 318
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6406
Mailing Address - Country:US
Mailing Address - Phone:512-203-3588
Mailing Address - Fax:
Practice Address - Street 1:1600 W 38TH ST STE 318
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731
Practice Address - Country:US
Practice Address - Phone:512-203-3588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP13164913682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1316491368OtherNPPES
TXAP122637OtherTEXAS BOARD OF NURSING
TXAP131368OtherTEXAS BOARD OF NURSING
TX1669658506OtherNPPES