Basic Information
| Provider Information | |||||||||
| NPI: | 1912296013 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MHMR AUTHORITY OF BRAZOS VALLEY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4588 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778054588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 S TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778033946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2011 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9798226467 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.