Provider Demographics
NPI:1174860266
Name:HENRY DAVID HARDT PH D
Entity Type:Organization
Organization Name:HENRY DAVID HARDT PH D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HARDT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:254-776-0400
Mailing Address - Street 1:4555 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1814
Mailing Address - Country:US
Mailing Address - Phone:254-776-0400
Mailing Address - Fax:254-776-0637
Practice Address - Street 1:4555 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-1814
Practice Address - Country:US
Practice Address - Phone:254-776-0400
Practice Address - Fax:254-776-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220734261QM0850X
TX3581-3582261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder