Basic Information
| Provider Information | |||||||||
| NPI: | 1851678072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRD | ||||||||
| FirstName: | TRUDY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M S LPC-S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | TRUDY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1336 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617773991 | ||||||||
| FaxNumber: | 3617770610 | ||||||||
| Practice Location | |||||||||
| Address1: | 2808 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | BEEVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613588000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 65077 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.