Provider Demographics
NPI:1215718184
Name:BLUEHAVEN PSYCHIATRY PLLC
Entity type:Organization
Organization Name:BLUEHAVEN PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NGOMENI
Authorized Official - Middle Name:M
Authorized Official - Last Name:MBILIKIRA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:214-432-1669
Mailing Address - Street 1:940 W FM 544 UNIT 625
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3330
Mailing Address - Country:US
Mailing Address - Phone:214-432-1669
Mailing Address - Fax:214-416-7823
Practice Address - Street 1:3960 BROADWAY BLVD STE 140
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-2593
Practice Address - Country:US
Practice Address - Phone:316-516-4972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty