Basic Information
| Provider Information | |||||||||
| NPI: | 1467483677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXARKANA BEHAVIORAL ASSOCIATES, L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALLEY BEHAVIORAL HEALTH SYSTEM OUTPATIENT PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 CRESCENT CENTRE DRIVE | ||||||||
| Address2: | SUITE 610 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158616000 | ||||||||
| FaxNumber: | 6152619685 | ||||||||
| Practice Location | |||||||||
| Address1: | 815A FORT STREET | ||||||||
| Address2: | |||||||||
| City: | BARLING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794945700 | ||||||||
| FaxNumber: | 4794945777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 09/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | HOWARD | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP & SECRETAY | ||||||||
| AuthorizedOfficialTelephone: | 6158616000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TEXARKANA BEHAVIORAL ASSOCIATES, L.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 261QM0801X | AR4283 | AR | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 5C855 | 01 | AR | BLUE CROSS GROUP | OTHER | 152583726 | 05 | AR | MEDICAID | 200012010A | 05 | OK | MEDICAID |