Provider Demographics
NPI:1720543895
Name:360 BEHAVIORAL HEALTH OF TEXAS LLC
Entity Type:Organization
Organization Name:360 BEHAVIORAL HEALTH OF TEXAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CHAIRMAN/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOGOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-285-8969
Mailing Address - Street 1:16946 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3613
Mailing Address - Country:US
Mailing Address - Phone:949-339-0401
Mailing Address - Fax:
Practice Address - Street 1:120 E SOUTH TOWN DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4747
Practice Address - Country:US
Practice Address - Phone:903-630-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CA PC MIDCO, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health