Provider Demographics
NPI:1508887241
Name:TRI-COUNTY BEHAVIORAL HEALTHCARE
Entity Type:Organization
Organization Name:TRI-COUNTY BEHAVIORAL HEALTHCARE
Other - Org Name:HOLLY STREET HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:REIMBURSEMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STANDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-521-6100
Mailing Address - Street 1:PO BOX 3067
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77305-3067
Mailing Address - Country:US
Mailing Address - Phone:936-521-6100
Mailing Address - Fax:
Practice Address - Street 1:1420 HOLLY ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3118
Practice Address - Country:US
Practice Address - Phone:936-521-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000756601Medicaid