Basic Information
| Provider Information | |||||||||
| NPI: | 1477669208 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTH TEXAS STATE HOSPITAL/WICHITA FALLS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 W 51ST ST # MC-E619 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787512312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124385618 | ||||||||
| FaxNumber: | 5124384220 | ||||||||
| Practice Location | |||||||||
| Address1: | 6515 KEMP BLVD | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763085419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406895201 | ||||||||
| FaxNumber: | 9406895784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARNETT | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5124385618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | TX | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0827958-01 | 05 | TX | MEDICAID | 4538344 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER | HH4614 | 01 | TX | BCBS PSYCHIATRIC | OTHER | 1372468-03 | 05 | TX | MEDICAID | 1372468-04 | 05 | TX | MEDICAID | 0638249-01 | 05 | TX | MEDICAID | HH3005 | 01 | TX | BCBS DRUG/ALCOHOL | OTHER | 0211955-01 | 05 | TX | MEDICAID | 1372468-02 | 05 | TX | MEDICAID |