Basic Information
| Provider Information | |||||||||
| NPI: | 1972511921 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAN ANTONIO STATE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 701 W 51ST ST # MC-E619 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787512312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124385618 | ||||||||
| FaxNumber: | 5124384220 | ||||||||
| Practice Location | |||||||||
| Address1: | 6711 S NEW BRAUNFELS AVE #100 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782233002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105317805 | ||||||||
| FaxNumber: | 2105317796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARNETT | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5124385618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | TX | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1387060-06 | 05 | TX | MEDICAID | 1387060-07 | 05 | TX | MEDICAID | HH4763 | 01 | TX | BCBS PSYCHIATRIC | OTHER | 0638264-01 | 05 | TX | MEDICAID | 1387060-04 | 05 | TX | MEDICAID | HH3015 | 01 | TX | BCBS DRUG/ALCOHOL | OTHER | 4589012 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER | 0827974-01 | 05 | TX | MEDICAID | 1387060-05 | 05 | TX | MEDICAID |