Provider Demographics
NPI:1568403574
Name:NORTHEAST TEXAS MENTAL HEALTH MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:NORTHEAST TEXAS MENTAL HEALTH MENTAL RETARDATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE & FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-831-3646
Mailing Address - Street 1:PO BOX 5637
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-5637
Mailing Address - Country:US
Mailing Address - Phone:903-831-7585
Mailing Address - Fax:903-831-4823
Practice Address - Street 1:1 C OAKLAWN CENTER
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-4159
Practice Address - Country:US
Practice Address - Phone:903-831-7585
Practice Address - Fax:903-831-4823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00PM39OtherBLUECROSSBLUESHIELD
TX00PM39Medicare ID - Type Unspecified