Provider Demographics
NPI:1306819511
Name:PSYCHOLOGICAL CONSULTANTS OF THE BRAZOS VALLEY PA
Entity Type:Organization
Organization Name:PSYCHOLOGICAL CONSULTANTS OF THE BRAZOS VALLEY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIIRECTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:979-774-9255
Mailing Address - Street 1:2400 BROADMOOR DR
Mailing Address - Street 2:STE C
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802
Mailing Address - Country:US
Mailing Address - Phone:979-774-9255
Mailing Address - Fax:979-774-9299
Practice Address - Street 1:2400 BROADMOOR DR
Practice Address - Street 2:STE C
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802
Practice Address - Country:US
Practice Address - Phone:979-774-9255
Practice Address - Fax:979-774-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32062103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0064LMOtherBLUE CROSS
TX0064LMOtherBLUE CROSS
TX00988WMedicare ID - Type Unspecified