Provider Demographics
NPI:1679741896
Name:LAKES REGIONAL MHMR CENTER
Entity Type:Organization
Organization Name:LAKES REGIONAL MHMR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-524-4159
Mailing Address - Street 1:400 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-4302
Mailing Address - Country:US
Mailing Address - Phone:972-524-4159
Mailing Address - Fax:972-563-0292
Practice Address - Street 1:4804 WESLEY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5650
Practice Address - Country:US
Practice Address - Phone:903-454-0300
Practice Address - Fax:903-454-8635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103098252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103098OtherPROFESSIONAL LICENSE NUMB