Basic Information
| Provider Information | |||||||||
| NPI: | 1659567238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRESSIVE BEHAVIORAL HEALTH, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROGRESSIVE BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 670687 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752670687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819933733 | ||||||||
| FaxNumber: | 2816482200 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 S FRIENDSWOOD DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | FRIENDSWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775463989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819933733 | ||||||||
| FaxNumber: | 2816482200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL-DUNN | ||||||||
| AuthorizedOfficialFirstName: | ANISHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 2819933733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N2254 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2114720-01 | 05 | TX | MEDICAID |