Provider Demographics
NPI:1326677212
Name:TX MC SPROUT 1 PLLC
Entity type:Organization
Organization Name:TX MC SPROUT 1 PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBCHYK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:469-904-0159
Mailing Address - Street 1:19 W 24TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3239
Mailing Address - Country:US
Mailing Address - Phone:833-458-0386
Mailing Address - Fax:855-461-3542
Practice Address - Street 1:325 N SAINT PAUL ST STE 3100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-3923
Practice Address - Country:US
Practice Address - Phone:626-699-0236
Practice Address - Fax:929-384-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-03
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty