Basic Information
| Provider Information | |||||||||
| NPI: | 1831343029 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9520 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799959520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157838164 | ||||||||
| FaxNumber: | 9157838187 | ||||||||
| Practice Location | |||||||||
| Address1: | 9849 KENWORTHY ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799244402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157573178 | ||||||||
| FaxNumber: | 9157838187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2008 | ||||||||
| LastUpdateDate: | 11/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9157838164 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 140114318 | 05 | TX | MEDICAID |