Provider Demographics
NPI:1952888265
Name:ELITE PSYCHIATRY PC
Entity Type:Organization
Organization Name:ELITE PSYCHIATRY PC
Other - Org Name:ELITE PSYCHIATRY PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MS
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:MODISETTE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP-BC
Authorized Official - Phone:817-695-5035
Mailing Address - Street 1:3901 ARLINGTON HIGHLANDS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-6050
Mailing Address - Country:US
Mailing Address - Phone:817-695-5035
Mailing Address - Fax:817-695-5037
Practice Address - Street 1:3901 ARLINGTON HIGHLANDS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-6050
Practice Address - Country:US
Practice Address - Phone:817-695-5035
Practice Address - Fax:817-695-5037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X, 2084P0804X, 363LF0000X, 363LP0808X
TXM97702084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM9770OtherTX MEDICAL BOARD
TXAP137299OtherAPRN LICENSE NUMBER