Basic Information
| Provider Information | |||||||||
| NPI: | 1790733905 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENIOR CONNECTIONS OF TEXAS PLLC | ||||||||
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| OtherOrganizationName: | SENIOR CONNECTIONS OF HOUSTON PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12012 WICKCHESTER LANE | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324482800 | ||||||||
| FaxNumber: | 8324482801 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 N HIGHWAY 290 | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786212510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324482800 | ||||||||
| FaxNumber: | 8324482801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | THORNELL | ||||||||
| AuthorizedOfficialFirstName: | ANGEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8324482800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | CG4009 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 0074AE | 01 | TX | BCBS | OTHER |