Basic Information
| Provider Information | |||||||||
| NPI: | 1679863450 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUSTIN TRAVIS COUNTY INTEGRAL CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4019 MANCHACA RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787046737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128043414 | ||||||||
| FaxNumber: | 5124472213 | ||||||||
| Practice Location | |||||||||
| Address1: | 4019 MANCHACA RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787046737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128043414 | ||||||||
| FaxNumber: | 5124472213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | KITCHING | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | DRUG COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 5127698789 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCDC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.