Provider Demographics
NPI:1114425824
Name:SQUARE 1 FAMILY SERVICES
Entity Type:Organization
Organization Name:SQUARE 1 FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-943-0252
Mailing Address - Street 1:1400 BROADFIELD BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-5162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 BROADFIELD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-5162
Practice Address - Country:US
Practice Address - Phone:757-943-0252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health