Provider Demographics
NPI:1811725708
Name:BEACON BEHAVIORAL OF TEXAS PA
Entity type:Organization
Organization Name:BEACON BEHAVIORAL OF TEXAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAVESKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-550-7536
Mailing Address - Street 1:22 PRESTIGE CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-3441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1604 HOSPITAL PKWY STE 507&508
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6986
Practice Address - Country:US
Practice Address - Phone:817-354-7268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON BEHAVIORAL OF TEXAS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty