Basic Information
Provider Information | |||||||||
NPI: | 1215236245 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COOK CHILDREN'S MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COOK CHILDREN'S NEUROSCIENCES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 99213 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761990213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6828854871 | ||||||||
FaxNumber: | 6828853936 | ||||||||
Practice Location | |||||||||
Address1: | 1500 COOPER ST | ||||||||
Address2: | 4TH FLOOR | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761042710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6828852500 | ||||||||
FaxNumber: | 6828851903 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2011 | ||||||||
LastUpdateDate: | 03/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RHOADES | ||||||||
AuthorizedOfficialFirstName: | CORY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CFO, CCHCS | ||||||||
AuthorizedOfficialTelephone: | 6828854480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COOK CHILDREN'S MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 000332 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   | 103G00000X | 000332 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
No ID Information.