Basic Information
| Provider Information | |||||||||
| NPI: | 1699021089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METROCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3330 S LANCASTER RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752164531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143710474 | ||||||||
| FaxNumber: | 2143713933 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 S LANCASTER RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752164531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143710474 | ||||||||
| FaxNumber: | 2143713933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2012 | ||||||||
| LastUpdateDate: | 08/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | WALLS | ||||||||
| AuthorizedOfficialFirstName: | LAZANE | ||||||||
| AuthorizedOfficialMiddleName: | SHERILYN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL MANAGER III | ||||||||
| AuthorizedOfficialTelephone: | 9728615917 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LPC, LCDC, ADC-III, | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 8802 | TX | N | Agencies | Community/Behavioral Health | 251S00000X | 15910 | TX | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0291080-03 | 05 | TX | MEDICAID |