Provider Demographics
NPI:1336619329
Name:CEREBRO LLC
Entity type:Organization
Organization Name:CEREBRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:903-946-1261
Mailing Address - Street 1:PO BOX 1041
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-1041
Mailing Address - Country:US
Mailing Address - Phone:903-946-1261
Mailing Address - Fax:
Practice Address - Street 1:307 E 1ST ST STE 10-4
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-2973
Practice Address - Country:US
Practice Address - Phone:903-946-1261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-03
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP139190OtherSTATE ADVANCED PRACTICE LICENSE