Basic Information
Provider Information | |||||||||
NPI: | 1720377591 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AUSTIN TRAVIS COUNTY MHMR CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AUSTIN TRAVIS COUNTY INTEGRAL CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3548 | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787643548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124724357 | ||||||||
FaxNumber: | 5127031394 | ||||||||
Practice Location | |||||||||
Address1: | 825 EAST RUNDBERG LANE, UNIT F | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 78753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128043900 | ||||||||
FaxNumber: | 5128043901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2011 | ||||||||
LastUpdateDate: | 04/01/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRISON | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFIER, COO | ||||||||
AuthorizedOfficialTelephone: | 5124404001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 166 - 3396 | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.