Basic Information
| Provider Information | |||||||||
| NPI: | 1033160825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VERICARE OF TEXAS, P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VERICARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1480 BOSTON POST RD | ||||||||
| Address2: | |||||||||
| City: | OLD SAYBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064751750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8775157147 | ||||||||
| Practice Location | |||||||||
| Address1: | 24025 KINGWOOD PLACE DR | ||||||||
| Address2: | |||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773393862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002578715 | ||||||||
| FaxNumber: | 8008191655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8605100888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0808X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 2084P0800X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | CG8005 | 01 | TX | RAILROAD MEDICARE | OTHER | 130082404 | 05 | TX | MEDICAID |