Basic Information
| Provider Information | |||||||||
| NPI: | 1003823030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
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| OtherOrganizationName: | AUSTIN STATE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | MC2023 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122065284 | ||||||||
| FaxNumber: | 5122065302 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124192843 | ||||||||
| FaxNumber: | 5124192683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCOUNTANT III | ||||||||
| AuthorizedOfficialTelephone: | 5122065284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 183500000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 2084F0202X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0800X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0805X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 208D00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 103G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | HH4750 | 01 | TX | BCBS PSYCHIATRIC | OTHER | HH3010 | 01 | TX | BCBS DRUG/ALCOHOL | OTHER | 0937807-01 | 05 | TX | MEDICAID | 0827875-01 | 05 | TX | MEDICAID | 4539637 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER |