Basic Information
Provider Information | |||||||||
NPI: | 1821698309 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BHG LXXII, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5001 SPRING VALLEY ROAD | ||||||||
Address2: | SUITE 600 EAST | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 75244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143656100 | ||||||||
FaxNumber: | 2143656150 | ||||||||
Practice Location | |||||||||
Address1: | 4373 DOWTOWNER LOOP SOUTH | ||||||||
Address2: | SUITE A | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 36609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514616961 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2020 | ||||||||
LastUpdateDate: | 10/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GASAWAY | ||||||||
AuthorizedOfficialFirstName: | JEMECE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF LICENSING | ||||||||
AuthorizedOfficialTelephone: | 2143656126 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSW, LMSW | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.