Provider Demographics
NPI:1609958628
Name:DEVEREUX FOUNDATION
Entity Type:Organization
Organization Name:DEVEREUX FOUNDATION
Other - Org Name:DEVEREUX TEXAS TREATMENT NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HELM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-335-1000
Mailing Address - Street 1:PO BOX 2666
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77902-2666
Mailing Address - Country:US
Mailing Address - Phone:361-575-8271
Mailing Address - Fax:361-575-6520
Practice Address - Street 1:120 DAVID WADE DRIVE
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77905
Practice Address - Country:US
Practice Address - Phone:361-575-8271
Practice Address - Fax:361-575-6520
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEVEREUX FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 2084P0804X
TX5460320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112748201Medicaid
TX112748202Medicaid
TX112748202Medicaid