Provider Demographics
NPI:1639788243
Name:GLC WELLNESS CENTER AUSTIN
Entity Type:Organization
Organization Name:GLC WELLNESS CENTER AUSTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:COLLINS
Authorized Official - Middle Name:WATTS
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:816-419-5756
Mailing Address - Street 1:3781 PARADISE HILLS DR APT 29201
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-2413
Mailing Address - Country:US
Mailing Address - Phone:816-419-5756
Mailing Address - Fax:
Practice Address - Street 1:3781 PARADISE HILLS DR APT 29201
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-2413
Practice Address - Country:US
Practice Address - Phone:816-419-5756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty