Provider Demographics
NPI:1639436678
Name:INSTITUTE OF DYNAMIC BEHAVIOR
Entity Type:Organization
Organization Name:INSTITUTE OF DYNAMIC BEHAVIOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:NGOZI
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-239-2152
Mailing Address - Street 1:3119 MULBERRY RANCH DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-3026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3119 MULBERRY RANCH DRIVE
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-3620
Practice Address - Country:US
Practice Address - Phone:832-239-2152
Practice Address - Fax:281-574-9026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004516Medicaid
TX114605Medicare UPIN
TX326700Medicare UPIN
TX004516Medicaid
TX143115Medicare Oscar/Certification
TX0234170051Medicare NSC