Basic Information
| Provider Information | |||||||||
| NPI: | 1386684793 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI COUNTY MENTAL HEALTH MENTAL RETARDATION SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3067 | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773053067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1506 FM 2854 RD | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773042206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | STANDLEY | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9365216136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 135242901 | 05 | TX | MEDICAID |