Basic Information
| Provider Information | |||||||||
| NPI: | 1659322733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRINITY CLINIC PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5500 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757125500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 S. BROADWAY, | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TYLER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 75701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035931786 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN CLINIC SUPPORT COORDINATO | ||||||||
| AuthorizedOfficialTelephone: | 9035101113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC, CMC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 101YP2500X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.