Provider Demographics
NPI:1134762636
Name:PRISTINE BEHAVIORAL THERAPY
Entity type:Organization
Organization Name:PRISTINE BEHAVIORAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL/BILLING
Authorized Official - Prefix:
Authorized Official - First Name:TRALICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BSN, COM
Authorized Official - Phone:817-962-0409
Mailing Address - Street 1:715 N FIELDER RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4695
Mailing Address - Country:US
Mailing Address - Phone:817-962-0409
Mailing Address - Fax:817-900-2475
Practice Address - Street 1:715 N FIELDER RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4695
Practice Address - Country:US
Practice Address - Phone:817-962-0409
Practice Address - Fax:817-900-2475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRISTINE TRANSLATIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty