Basic Information
| Provider Information | |||||||||
| NPI: | 1326202870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLIN COUNTY MENTAL HEALTH MENTAL RETARDATION CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIFEPATH SYSTEMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 HERITAGE DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | MCKINNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750693378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725620190 | ||||||||
| FaxNumber: | 9725623647 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 HERITAGE DR | ||||||||
| Address2: | 105 | ||||||||
| City: | MCKINNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750693256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725620190 | ||||||||
| FaxNumber: | 9726650076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2008 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARR | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS | ||||||||
| AuthorizedOfficialTelephone: | 9725620190 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 252Y00000X | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | 017420301 | 05 | TX | MEDICAID |