Provider Demographics
NPI:1679638639
Name:NOAH'S GLEN RESIDENTIAL TREATMENT CENTER
Entity Type:Organization
Organization Name:NOAH'S GLEN RESIDENTIAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:T
Authorized Official - Last Name:FARENTHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:713-683-9144
Mailing Address - Street 1:2121 MANSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77091-4033
Mailing Address - Country:US
Mailing Address - Phone:713-683-9144
Mailing Address - Fax:713-683-9143
Practice Address - Street 1:2121 MANSFIELD ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77091-4033
Practice Address - Country:US
Practice Address - Phone:713-683-9144
Practice Address - Fax:713-683-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2362A3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2362AOtherDSHS