Provider Demographics
NPI:1053287045
Name:IDERA BEHAVIORAL HEALTH PLLC
Entity type:Organization
Organization Name:IDERA BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BABATUNDE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHITTU
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:817-217-0662
Mailing Address - Street 1:3036 LARRETA
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6794
Mailing Address - Country:US
Mailing Address - Phone:817-217-0662
Mailing Address - Fax:
Practice Address - Street 1:3036 LARRETA
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-6794
Practice Address - Country:US
Practice Address - Phone:817-217-0662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-15
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty