Provider Demographics
NPI:1477932119
Name:ABUNDANT LIFE THERAPEUTIC SERVICES TEXAS
Entity Type:Organization
Organization Name:ABUNDANT LIFE THERAPEUTIC SERVICES TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-666-4685
Mailing Address - Street 1:260 N SAM HOUSTON PKWY E STE 350
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-2024
Mailing Address - Country:US
Mailing Address - Phone:832-300-8680
Mailing Address - Fax:832-300-8685
Practice Address - Street 1:260 N SAM HOUSTON PKWY E STE 350
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-2024
Practice Address - Country:US
Practice Address - Phone:832-300-8680
Practice Address - Fax:832-300-8685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68144101YP2500X
251B00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)