Provider Demographics
| NPI: | 1730135864 |
|---|---|
| Name: | BLUEBONNET TRAILS COMMUNITY MHMR CENTER |
| Entity type: | Organization |
| Organization Name: | BLUEBONNET TRAILS COMMUNITY MHMR CENTER |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | MANAGER |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | AMY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | BODKINS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 512-244-8374 |
| Mailing Address - Street 1: | 1009 N GEORGETOWN ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | ROUND ROCK |
| Mailing Address - State: | TX |
| Mailing Address - Zip Code: | 78664-3289 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 512-255-1720 |
| Mailing Address - Fax: | 512-244-8371 |
| Practice Address - Street 1: | 1009 N GEORGETOWN ST |
| Practice Address - Street 2: | |
| Practice Address - City: | ROUND ROCK |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 78664-3289 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 512-255-1720 |
| Practice Address - Fax: | 512-244-8371 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-26 |
| Last Update Date: | 2023-08-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
| No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities | Group - Multi-Specialty |
| No | 103TR0400X | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TX | 1268443 03 | Medicaid | |
| TX | 0797201 01 | Medicaid | |
| TX | 1268443 02 | Medicaid | |
| TX | 1268443 05 | Medicaid | |
| TX | 1268443 04 | Medicaid | |
| TX | 1268443 01 | Medicaid | |
| TX | 1268443 05 | Medicaid |
