Basic Information
| Provider Information | |||||||||
| NPI: | 1760141733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENTAL ASPECTS BEHAVIORAL HEALTH CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12702 TOEPPERWEIN RD STE 236 | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104753617 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12702 TOEPPERWEIN RD STE 236 | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104753617 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2021 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | LICORISH | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2104753617 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.