Provider Demographics
NPI:1699945360
Name:SUMMIT MENTAL HEALTH CLINIC PA
Entity type:Organization
Organization Name:SUMMIT MENTAL HEALTH CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCISCA
Authorized Official - Middle Name:ADA
Authorized Official - Last Name:IFESINACHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-732-2122
Mailing Address - Street 1:PO BOX 17906
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78760-7906
Mailing Address - Country:US
Mailing Address - Phone:512-732-2122
Mailing Address - Fax:
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:BLDG#L, #2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-732-2122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1620261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00773XOtherMEDICARE GROUP #
TX153758102Medicaid
TX173311501OtherTPI
TX8C9871Medicare PIN
TX173311501OtherTPI