Provider Demographics
NPI:1619196169
Name:CENTRAL TEXAS MENTAL HEALTH AND MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:CENTRAL TEXAS MENTAL HEALTH AND MENTAL RETARDATION CENTER
Other - Org Name:CENTER FOR LIFE RESOURCES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DION
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-646-9574
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76804-0250
Mailing Address - Country:US
Mailing Address - Phone:325-646-9574
Mailing Address - Fax:325-643-5136
Practice Address - Street 1:408 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-1639
Practice Address - Country:US
Practice Address - Phone:325-646-9574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13184101Y00000X
TX64151101Y00000X
TX66441101Y00000X
TX09663101YP2500X
TX13474101YP2500X
TX167801041C0700X
TXC91642084P0800X
251B00000X, 251S00000X, 261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133339507Medicaid
TX000384001Medicaid
TX000732501Medicaid
TX1333395-01Medicaid
TX1333395-04Medicaid
TX000373401Medicaid
TX1333395-02Medicaid
TX000732501Medicaid