Provider Demographics
NPI:1104921642
Name:KUNNATHUSSERIL, JOHN A (MAMTH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:KUNNATHUSSERIL
Suffix:
Gender:M
Credentials:MAMTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 SIMMONS DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-462-8246
Mailing Address - Fax:
Practice Address - Street 1:4525 LEMMON AVE
Practice Address - Street 2:STE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219
Practice Address - Country:US
Practice Address - Phone:214-526-4525
Practice Address - Fax:214-520-6468
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7675101YP2500X
TX2886106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148198OtherVALUE OPTION NORTH STAR