Provider Demographics
NPI:1811189806
Name:CENTRAL PINES PSYCHOLOGICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:CENTRAL PINES PSYCHOLOGICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:ULRIK
Authorized Official - Last Name:MICHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:210-473-4729
Mailing Address - Street 1:PO BOX 1003
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-1003
Mailing Address - Country:US
Mailing Address - Phone:512-529-1538
Mailing Address - Fax:210-579-6582
Practice Address - Street 1:1011 ALLEY A ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3240
Practice Address - Country:US
Practice Address - Phone:512-529-1538
Practice Address - Fax:210-579-6582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33431103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN
TX=========OtherEIN