Basic Information
Provider Information | |||||||||
NPI: | 1578685301 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MY HEALTH MY RESOURCES OF TARRANT COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MHMR OF TARRANT COUNTY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2603 | ||||||||
Address2: | HTN, CLIENT ACCOUNTING | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761132603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175694395 | ||||||||
FaxNumber: | 8175694517 | ||||||||
Practice Location | |||||||||
Address1: | 3840 HULEN ST | ||||||||
Address2: | HTN, CLIENT ACCOUNTING | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 76107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175694395 | ||||||||
FaxNumber: | 8175694517 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 06/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARKER | ||||||||
AuthorizedOfficialFirstName: | BENITA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8175694300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X |   | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X |   | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 171M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 135082902 | 05 | TX |   | MEDICAID |