Basic Information
| Provider Information | |||||||||
| NPI: | 1558597138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASSURA SOURCE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12700 HILLCREST RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331010 | ||||||||
| FaxNumber: | 9722331099 | ||||||||
| Practice Location | |||||||||
| Address1: | 12700 HILLCREST RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331010 | ||||||||
| FaxNumber: | 9722331099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2009 | ||||||||
| LastUpdateDate: | 06/09/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | KATE | ||||||||
| AuthorizedOfficialTitleorPosition: | PYSCO THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9722914098 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW,ACP,PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 08268 | TX | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.