Basic Information
| Provider Information | |||||||||
| NPI: | 1366607897 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXARKANA BEHAVIORAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERVIEW BEHAVIORAL HEALTH OUTPATIENT PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 CRESCENT GATE DRIVE | ||||||||
| Address2: | SUITE 610 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158616000 | ||||||||
| FaxNumber: | 6152619685 | ||||||||
| Practice Location | |||||||||
| Address1: | 1484 WEST 1ST STREET, NORTH | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707725028 | ||||||||
| FaxNumber: | 8707741146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | HOWARD | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6158616000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TEXARKANA BEHAVIORAL ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | AR | MEDICARE | OTHER | PENDING | 05 | AR | MEDICAID | PENDING | 01 | AR | BLUE CROSS | OTHER |