Basic Information
| Provider Information | |||||||||
| NPI: | 1720268949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAPEVINE VALLEY HOPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 WILLIAM D TATE AVE | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174249013 | ||||||||
| FaxNumber: | 8173290974 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 WILLIAM D TATE AVE | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174249013 | ||||||||
| FaxNumber: | 8173290974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | WEBB | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | OUTPATIENT PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8174249013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VALLEY HOPE ASSOCIATION | ||||||||
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| AuthorizedOfficialCredential: | MA, LCDC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 9838 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.