Basic Information
| Provider Information | |||||||||
| NPI: | 1710364153 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH MENTAL RETARDATION AUTHORITY BRAZOS VALLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1504 S TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778021015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Practice Location | |||||||||
| Address1: | 1504 S TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778021015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9798226467 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1363665 | 05 | TX | MEDICAID |