Basic Information
| Provider Information | |||||||||
| NPI: | 1386778405 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERIATRIC MENTAL HEALTH SPECIALISTS INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 CANDLE PINE PL | ||||||||
| Address2: | #100 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773816436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9362733786 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2504 BLISS SPILLAR RD | ||||||||
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| City: | MANCHACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786524409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122823723 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | ORTEGA | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9362733786 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 125999603 | 05 | TX | MEDICAID |