NPIMap

Organization Active NPI

Deep Eddy Psychotherapy Management, LLC

  • Counseling Psychologist
  • Austin, TX
National Provider Identifier
1457740862
Registry record updated Dec 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Counseling PsychologistTaxonomy code 103TC1900X
License
34890 Issued in TX
Legal business name
DEEP EDDY PSYCHOTHERAPY MANAGEMENT, LLC
Practice address
508 Deep Eddy Ave.
Austin, TX 78703
Phone
(512) 956-6463
Fax
(512) 428-8100
NPI assigned
Jan 22, 2015
Last updated
Dec 27, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 27, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Glenn R. Olds, PH.D.NPI 1033496799
Title
Managing Psychologist
Phone
(512) 217-9579

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC0700X 21274 TX
Counseling PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC1900X 34890 TX Primary
Counseling PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC1900X 34301 TX
Counseling PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC1900X 20938 TX
Counseling PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC1900X 33076 TX

Addresses

Primary practice location

508 Deep Eddy Ave.
Austin, TX 78703

Mailing address

508 Deep Eddy Ave.
Austin, TX 78703
Phone (512) 461-0239

Other names 1

  • Deep Eddy Psychotherapy, PLLC Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230928002745 TX Part B Supplier - Clinic/Group Practice 2264886936 Receives reassigned benefits from 109 practitioners
Practice locations: Rockwall, TX; Austin, TX; San Antonio, TX; Round Rock, TX; Rollingwood, TX; Plano, TX; McKinney, TX; Houston, TX…

National Provider Directory

National Provider Directory

Locations

2600 W Stassney Ln
Austin, TX 78745
Phone (512) 469-0889

508 Deep Eddy Ave
Austin, TX 78703
Phone (512) 469-0889

8350 N Central Expy
Ste 1900
Dallas, TX 75206
Phone (469) 942-9483

4126 Southwest Fwy
Ste 600
Houston, TX 77027
Phone (713) 626-9971

1010 W Ralph Hall Pkwy
Ste 112
Rockwall, TX 75032
Phone (469) 442-7366

500 Turtle Cove Blvd
Ste 101
Rockwall, TX 75087
Phone (817) 907-5051

1922 Dry Creek Way
Ste 108
San Antonio, TX 78259
Phone (512) 887-3993

Practitioners & affiliated clinicians

Practitioners 139

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 139

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1421884800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1672099200000",
    "number": "1457740862",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "508 DEEP EDDY AVE.",
            "city": "AUSTIN",
            "state": "TX",
            "postal_code": "78703",
            "telephone_number": "512-461-0239",
            "fax_number": "512-428-8100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "508 DEEP EDDY AVE.",
            "city": "AUSTIN",
            "state": "TX",
            "postal_code": "78703",
            "telephone_number": "512-956-6463",
            "fax_number": "512-428-8100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEEP EDDY PSYCHOTHERAPY MANAGEMENT, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-01-22",
        "last_updated": "2022-12-27",
        "certification_date": "2022-12-27",
        "status": "A",
        "authorized_official_last_name": "OLDS",
        "authorized_official_first_name": "GLENN",
        "authorized_official_middle_name": "R.",
        "authorized_official_title_or_position": "MANAGING PSYCHOLOGIST",
        "authorized_official_telephone_number": "512-217-9579",
        "authorized_official_credential": "PH.D."
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "TX",
            "license": "21274",
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": "TX",
            "license": "34890",
            "primary": true
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": "TX",
            "license": "34301",
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": "TX",
            "license": "20938",
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": "TX",
            "license": "33076",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deep Eddy Psychotherapy, PLLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Austin, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.