Provider Demographics
NPI:1710364153
Name:MENTAL HEALTH MENTAL RETARDATION AUTHORITY BRAZOS VALLEY
Entity Type:Organization
Organization Name:MENTAL HEALTH MENTAL RETARDATION AUTHORITY BRAZOS VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-822-6467
Mailing Address - Street 1:1504 S TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1015
Mailing Address - Country:US
Mailing Address - Phone:979-822-6467
Mailing Address - Fax:979-821-9448
Practice Address - Street 1:1504 S TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1015
Practice Address - Country:US
Practice Address - Phone:979-822-6467
Practice Address - Fax:979-821-9448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1363665Medicaid