Basic Information
| Provider Information | |||||||||
| NPI: | 1366182164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND VISTA BEHAVIORAL HEALTH CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9711 S MASON RD STE 125-215 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774077167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3469332463 | ||||||||
| FaxNumber: | 7132347382 | ||||||||
| Practice Location | |||||||||
| Address1: | 9711 S MASON RD STE 125-215 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774077167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3469332463 | ||||||||
| FaxNumber: | 7132347382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2022 | ||||||||
| LastUpdateDate: | 05/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BLESSING | ||||||||
| AuthorizedOfficialMiddleName: | UCHECHUKWU | ||||||||
| AuthorizedOfficialTitleorPosition: | PMHNP-BC | ||||||||
| AuthorizedOfficialTelephone: | 8323520845 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 05/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.