Provider Demographics
NPI:1518536309
Name:BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Entity Type:Organization
Organization Name:BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Other - Org Name:BLUEBONNET TRAILS COMMUNITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-244-8305
Mailing Address - Street 1:1009 N GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-3289
Mailing Address - Country:US
Mailing Address - Phone:512-255-1720
Mailing Address - Fax:512-244-8401
Practice Address - Street 1:750 W TRAVIS ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-2522
Practice Address - Country:US
Practice Address - Phone:512-255-1720
Practice Address - Fax:512-244-8401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-24
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1268443-05Medicaid