Basic Information
| Provider Information | |||||||||
| NPI: | 1134326192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIRSHENBAUM | ||||||||
| FirstName: | GEO-ANNA | ||||||||
| MiddleName: | QUINTANILLA | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD 706 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14100 KARISSA CT | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770493866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
| FaxNumber: | 2105939863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 11/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 37194 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 186053803 | 05 | TX | MEDICAID | 186053802 | 05 | TX | MEDICAID | 186053801 | 05 | TX | MEDICAID |