Provider Demographics
NPI:1528810439
Name:WITS SPECIALTY CLINIC PLLC
Entity type:Organization
Organization Name:WITS SPECIALTY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ NP
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:210-322-0191
Mailing Address - Street 1:9422 COPPERWAY
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2063
Mailing Address - Country:US
Mailing Address - Phone:210-322-0191
Mailing Address - Fax:
Practice Address - Street 1:9000 TESORO DR STE 103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6100
Practice Address - Country:US
Practice Address - Phone:210-322-0191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty