Provider Demographics
NPI:1760141733
Name:MENTAL ASPECTS BEHAVIORAL HEALTH CLINIC
Entity Type:Organization
Organization Name:MENTAL ASPECTS BEHAVIORAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LICORISH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:210-475-3617
Mailing Address - Street 1:12702 TOEPPERWEIN RD STE 236
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3231
Mailing Address - Country:US
Mailing Address - Phone:210-475-3617
Mailing Address - Fax:
Practice Address - Street 1:12702 TOEPPERWEIN RD STE 236
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3231
Practice Address - Country:US
Practice Address - Phone:210-475-3617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty