Provider Demographics
NPI:1689924045
Name:OVERLOOKED BEHAVIROL PROGRAM
Entity Type:Organization
Organization Name:OVERLOOKED BEHAVIROL PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-499-4235
Mailing Address - Street 1:19411 CACTUS ROSE
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449
Mailing Address - Country:US
Mailing Address - Phone:832-499-4235
Mailing Address - Fax:281-829-5566
Practice Address - Street 1:19411 CACTUS ROSE
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449
Practice Address - Country:US
Practice Address - Phone:832-499-4235
Practice Address - Fax:281-829-5566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty