Basic Information
| Provider Information | |||||||||
| NPI: | 1740767607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEAR WATER PSYCHIATRY & WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W 38TH ST STE 318 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122033588 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 W 38TH ST STE 318 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122033588 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2018 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | GOLD | ||||||||
| AuthorizedOfficialFirstName: | TORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5122033588 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | AP1316491368 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1316491368 | 01 | TX | NPPES | OTHER | AP122637 | 01 | TX | TEXAS BOARD OF NURSING | OTHER | AP131368 | 01 | TX | TEXAS BOARD OF NURSING | OTHER | 1669658506 | 01 | TX | NPPES | OTHER |