Basic Information
| Provider Information | |||||||||
| NPI: | 1982623732 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-COUNTY BEHAVIORAL HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LEE STREET HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3067 | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773053067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 802 LEE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773275127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 04/27/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STANDLEY | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9365216100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 000390401 | 05 | TX | MEDICAID |