Provider Demographics
NPI:1801625926
Name:GRASSROOT PSYCHIATRY AND MENTAL HEALTH CLINIC PLLC
Entity type:Organization
Organization Name:GRASSROOT PSYCHIATRY AND MENTAL HEALTH CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:EZIGBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-220-3534
Mailing Address - Street 1:2100 N HWY 360
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-1011
Mailing Address - Country:US
Mailing Address - Phone:682-214-0636
Mailing Address - Fax:
Practice Address - Street 1:101 ELLIOTT AVE W, SUITE 500
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-4292
Practice Address - Country:US
Practice Address - Phone:682-453-6176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-29
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty