Provider Demographics
NPI:1336417369
Name:SOUTHLAKE PSYCHOLOGICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:SOUTHLAKE PSYCHOLOGICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:817-488-3538
Mailing Address - Street 1:211 E SOUTHLAKE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6274
Mailing Address - Country:US
Mailing Address - Phone:817-488-3538
Mailing Address - Fax:
Practice Address - Street 1:211 E SOUTHLAKE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6274
Practice Address - Country:US
Practice Address - Phone:817-488-3538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34625103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty