Provider Demographics
NPI:1922505551
Name:GLEN FOREST PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:GLEN FOREST PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:512-767-1136
Mailing Address - Street 1:3006 BEE CAVES RD STE A212
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5767
Mailing Address - Country:US
Mailing Address - Phone:512-767-1136
Mailing Address - Fax:
Practice Address - Street 1:3006 BEE CAVES RD STE A212
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5767
Practice Address - Country:US
Practice Address - Phone:512-767-1136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-10
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017720103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty