Basic Information
| Provider Information | |||||||||
| NPI: | 1255365375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER AMARILLO | ||||||||
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| OtherOrganizationName: | TEXAS TECH UHSC PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 WALLACE BLVD | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149562 | ||||||||
| FaxNumber: | 8063564673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149970 | ||||||||
| FaxNumber: | 8063513783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | UNIT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8064149565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 084567901 | 05 | TX | MEDICAID | 100759180B | 05 | OK | MEDICAID | G4070 | 05 | NM | MEDICAID |