Provider Demographics
NPI:1134670649
Name:SUCCESS TRACK LLC
Entity Type:Organization
Organization Name:SUCCESS TRACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLLA
Authorized Official - Middle Name:MERLE
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:210-859-7854
Mailing Address - Street 1:9352 OSAGE CIR
Mailing Address - Street 2:
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2060
Mailing Address - Country:US
Mailing Address - Phone:201-859-7854
Mailing Address - Fax:210-745-4677
Practice Address - Street 1:9352 OSAGE CIR
Practice Address - Street 2:
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2060
Practice Address - Country:US
Practice Address - Phone:201-859-7854
Practice Address - Fax:210-745-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14527251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health