Basic Information
| Provider Information | |||||||||
| NPI: | 1548513195 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS CHILD STUDY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W 38TH ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243315 | ||||||||
| FaxNumber: | 5123243314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W 38TH ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243315 | ||||||||
| FaxNumber: | 5123243314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2012 | ||||||||
| LastUpdateDate: | 10/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | STARK | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5123243315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 36256 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.