Provider Demographics
NPI:1811415243
Name:GEBREMEDHIN, DAWIT MEHRETAB
Entity Type:Individual
Prefix:MR
First Name:DAWIT
Middle Name:MEHRETAB
Last Name:GEBREMEDHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 LBJ FWY STE 615
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6210
Mailing Address - Country:US
Mailing Address - Phone:972-331-6363
Mailing Address - Fax:
Practice Address - Street 1:5580 LBJ FWY STE 615
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6210
Practice Address - Country:US
Practice Address - Phone:972-331-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-17-40134106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician