Provider Demographics
NPI:1801404504
Name:OLIVE GREEN BEHAVIORAL HEALTH SERVICES PLLC
Entity Type:Organization
Organization Name:OLIVE GREEN BEHAVIORAL HEALTH SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAIUS-ANYAEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-422-7555
Mailing Address - Street 1:539 W COMMERCE ST # 935
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E DEBBIE LN
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2924
Practice Address - Country:US
Practice Address - Phone:682-422-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty