Basic Information
| Provider Information | |||||||||
| NPI: | 1669542155 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF STATE HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EL PASO PSYCHIATRIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4615 ALAMEDA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155322202 | ||||||||
| FaxNumber: | 9155345587 | ||||||||
| Practice Location | |||||||||
| Address1: | 4615 ALAMEDA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155322202 | ||||||||
| FaxNumber: | 9155345587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | IBARRA | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9155345316 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | X | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 283Q00000X | X | Hospitals | Psychiatric Hospital |
No ID Information.