Provider Demographics
NPI:1457740862
Name:DEEP EDDY PSYCHOTHERAPY MANAGEMENT, LLC
Entity Type:Organization
Organization Name:DEEP EDDY PSYCHOTHERAPY MANAGEMENT, LLC
Other - Org Name:DEEP EDDY PSYCHOTHERAPY, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:OLDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:512-217-9579
Mailing Address - Street 1:508 DEEP EDDY AVE.
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703
Mailing Address - Country:US
Mailing Address - Phone:512-461-0239
Mailing Address - Fax:512-428-8100
Practice Address - Street 1:508 DEEP EDDY AVE.
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703
Practice Address - Country:US
Practice Address - Phone:512-956-6463
Practice Address - Fax:512-428-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21274103TC0700X
TX34890103TC1900X
TX34301103TC1900X
TX20938103TC1900X
TX33076103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty