Basic Information
| Provider Information | |||||||||
| NPI: | 1942596903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENIOR PSYCHCARE OF DALLAS I, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4635 SOUTHWEST FWY STE 635 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770277112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138500049 | ||||||||
| FaxNumber: | 7136277302 | ||||||||
| Practice Location | |||||||||
| Address1: | 4635 SOUTHWEST FWY STE 635 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770277112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138500049 | ||||||||
| FaxNumber: | 7136277302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | FRAPART | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7138500049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PSYCHIATRIC SERVICES, PLLC | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 288003102 | 05 | TX | MEDICAID | 288003103 | 05 | TX | MEDICAID | 288003104 | 05 | TX | MEDICAID | DS2656 | 01 | TX | RR MCR HARRIS | OTHER | 0095WY | 01 | TX | BCBS TX | OTHER | 288003101 | 05 | TX | MEDICAID |